Provider Demographics
NPI:1891130951
Name:SANDOVAL, CECIL C (DDS)
Entity Type:Individual
Prefix:DR
First Name:CECIL
Middle Name:C
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 DALIES AVE
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-3615
Mailing Address - Country:US
Mailing Address - Phone:505-864-8912
Mailing Address - Fax:505-864-2142
Practice Address - Street 1:601 DALIES AVE
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-3615
Practice Address - Country:US
Practice Address - Phone:505-864-8912
Practice Address - Fax:505-864-2142
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM14521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice