Provider Demographics
NPI:1316940315
Name:CALLEROS, SANDRA (DDS)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:CALLEROS
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 1:131 W GRAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3738
Mailing Address - Country:US
Mailing Address - Phone:310-414-9564
Mailing Address - Fax:310-414-9773
Practice Address - Street 1:131 W GRAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3738
Practice Address - Country:US
Practice Address - Phone:310-414-9564
Practice Address - Fax:310-414-9773
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA354781223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice