Provider Demographics
NPI:1316775166
Name:PRIYAWAT, SANDY (DDS)
Entity type:Individual
Prefix:DR
First Name:SANDY
Middle Name:
Last Name:PRIYAWAT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S STATE COLLEGE BLVD UNIT 460
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-1617
Mailing Address - Country:US
Mailing Address - Phone:951-905-4058
Mailing Address - Fax:
Practice Address - Street 1:2071 RANCHO VALLEY DR STE 140
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-7105
Practice Address - Country:US
Practice Address - Phone:909-374-1815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-23
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110348122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist