Provider Demographics
NPI:1588663694
Name:CECIL C SANDOVAL DDS PA
Entity Type:Organization
Organization Name:CECIL C SANDOVAL DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIS
Authorized Official - Prefix:
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:C
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-864-8912
Mailing Address - Street 1:601 DALIES AVE
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-3615
Mailing Address - Country:US
Mailing Address - Phone:505-864-8912
Mailing Address - Fax:505-864-2157
Practice Address - Street 1:601 DALIES AVE
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-3615
Practice Address - Country:US
Practice Address - Phone:505-864-8912
Practice Address - Fax:505-864-2157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMD1452122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty