Provider Demographics
NPI:1700393998
Name:PENNER, SANDY GAIL (RDH)
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:GAIL
Last Name:PENNER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:SANDY
Other - Middle Name:GAIL
Other - Last Name:MACHOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:670 9TH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6249
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8160
Practice Address - Country:US
Practice Address - Phone:707-465-4636
Practice Address - Fax:707-465-6070
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31737124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist