Provider Demographics
NPI:1851444186
Name:MAZARIS, SANDRA ANNE
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:ANNE
Last Name:MAZARIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:ANNE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:6200 28TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6930
Mailing Address - Country:US
Mailing Address - Phone:616-949-4650
Mailing Address - Fax:
Practice Address - Street 1:6200 28TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6930
Practice Address - Country:US
Practice Address - Phone:616-949-4650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010188871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice