Provider Demographics
NPI:1578956447
Name:YEN, SANDRA L (DDS)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:YEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1390 N MCDOWELL BLVD STE G #344
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-7104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 MEDICAL CENTER DR STE B
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2902
Practice Address - Country:US
Practice Address - Phone:707-978-2077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA641741223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program