Provider Demographics
NPI:1790179257
Name:OTERO, SANDRA MICHELLE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:MICHELLE
Last Name:OTERO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:SANDRA
Other - Middle Name:MICHELLE
Other - Last Name:PEACOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:2 RUBIN DR
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14544-9681
Mailing Address - Country:US
Mailing Address - Phone:585-554-4400
Mailing Address - Fax:
Practice Address - Street 1:2 RUBIN DR
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:NY
Practice Address - Zip Code:14544-9681
Practice Address - Country:US
Practice Address - Phone:585-554-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021460124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist