Provider Demographics
NPI:1760797047
Name:LARA, SANDRA PATRICIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:PATRICIA
Last Name:LARA
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 1:1360 N WINCHESTER BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1150
Mailing Address - Country:US
Mailing Address - Phone:408-248-2617
Mailing Address - Fax:408-248-2618
Practice Address - Street 1:1360 N WINCHESTER BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1150
Practice Address - Country:US
Practice Address - Phone:408-248-2617
Practice Address - Fax:408-248-2618
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59648122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist