Provider Demographics
NPI:1063988301
Name:SISNEROS, SARAH ADELE (RDH)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:ADELE
Last Name:SISNEROS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 RAILCAR RD
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-7909
Mailing Address - Country:US
Mailing Address - Phone:505-401-9705
Mailing Address - Fax:
Practice Address - Street 1:333 SAN MATEO BLVD SE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2919
Practice Address - Country:US
Practice Address - Phone:505-268-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-14
Last Update Date:2018-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH4914124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist