Provider Demographics
NPI:1457547937
Name:SANDOVAL, ELIZABETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 BROAD ST STE 3E
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2844
Mailing Address - Country:US
Mailing Address - Phone:973-338-1100
Mailing Address - Fax:973-338-1059
Practice Address - Street 1:1025 BROAD ST STE 3
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2844
Practice Address - Country:US
Practice Address - Phone:973-338-1100
Practice Address - Fax:973-338-1059
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053693-11223G0001X
NJ22DI022333001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice