Provider Demographics
NPI:1669649901
Name:IACOB, SANDRA MARIA (DDS)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:MARIA
Last Name:IACOB
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 1:11808 SE SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9308
Mailing Address - Country:US
Mailing Address - Phone:503-698-1112
Mailing Address - Fax:503-698-1119
Practice Address - Street 1:11808 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9308
Practice Address - Country:US
Practice Address - Phone:503-698-1112
Practice Address - Fax:503-698-1119
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8175122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist