Provider Demographics
NPI:1972097483
Name:HENRIQUEZ, SANDRA MICHELLE (RDHAP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MICHELLE
Last Name:HENRIQUEZ
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:MRS
Other - First Name:SANDRA
Other - Middle Name:MICHELLE
Other - Last Name:HENRIQUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDHAP
Mailing Address - Street 1:3163 IVY ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-3212
Mailing Address - Country:US
Mailing Address - Phone:310-694-7421
Mailing Address - Fax:310-839-7367
Practice Address - Street 1:3163 IVY ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-3212
Practice Address - Country:US
Practice Address - Phone:310-694-7421
Practice Address - Fax:310-839-7367
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA698124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist