Provider Demographics
NPI:1891188371
Name:SANDRA CALLEROS, A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:SANDRA CALLEROS, A PROFESSIONAL CORP
Other - Org Name:CALLEROS DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLEROS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-414-9564
Mailing Address - Street 1:131 W GRAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3738
Mailing Address - Country:US
Mailing Address - Phone:310-414-9564
Mailing Address - Fax:310-414-9773
Practice Address - Street 1:131 W GRAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3738
Practice Address - Country:US
Practice Address - Phone:310-414-9564
Practice Address - Fax:310-414-9773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA354781223G0001X
CA629021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty