Provider Demographics
NPI:1497219604
Name:GOMEZ, SANDRA YANIRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:YANIRA
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:YANIRA
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12665 SERRANO DR
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-1744
Mailing Address - Country:US
Mailing Address - Phone:714-559-8503
Mailing Address - Fax:
Practice Address - Street 1:3380 LA SIERRA AVE STE 108
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5225
Practice Address - Country:US
Practice Address - Phone:951-465-6982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA78245126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDA78245Medicaid