Provider Demographics
NPI:1316785561
Name:AL TALLY, SARA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:AL TALLY
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 1:59 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:CALIMESA
Mailing Address - State:CA
Mailing Address - Zip Code:92320-2013
Mailing Address - Country:US
Mailing Address - Phone:682-360-3127
Mailing Address - Fax:
Practice Address - Street 1:4488 YUCAIPA BLVD STE A
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399
Practice Address - Country:US
Practice Address - Phone:909-801-8154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1102221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice