Provider Demographics
NPI:1881690535
Name:SANDOVAL, IVAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PANORAMAVILLAGE
Mailing Address - Street 2:#180 VISTA DEL MAR
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00957
Mailing Address - Country:US
Mailing Address - Phone:787-730-4449
Mailing Address - Fax:787-785-9054
Practice Address - Street 1:AQ-34 SANTA JUANITA
Practice Address - Street 2:AVE. LAUREL
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956
Practice Address - Country:US
Practice Address - Phone:787-798-6227
Practice Address - Fax:787-785-9054
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR20021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice