Provider Demographics
NPI:1629291638
Name:CERVANTES, ANDREA RAQUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:RAQUEL
Last Name:CERVANTES
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 1:12393 KEATING RD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CA
Mailing Address - Zip Code:95693-9679
Mailing Address - Country:US
Mailing Address - Phone:916-214-1725
Mailing Address - Fax:916-687-1004
Practice Address - Street 1:8835 SHELDON RD
Practice Address - Street 2:SUITE 140
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-5046
Practice Address - Country:US
Practice Address - Phone:916-681-8835
Practice Address - Fax:916-687-1004
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51554122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist