Provider Demographics
NPI:1245636133
Name:CASTILLO, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17103 N BAY RD
Mailing Address - Street 2:APT A208
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-3981
Mailing Address - Country:US
Mailing Address - Phone:305-949-5252
Mailing Address - Fax:305-949-5011
Practice Address - Street 1:17103 N BAY RD
Practice Address - Street 2:APT A208
Practice Address - City:SUNNY ISLES BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-3981
Practice Address - Country:US
Practice Address - Phone:305-949-5252
Practice Address - Fax:305-949-5011
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20757122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist