Provider Demographics
NPI:1386328862
Name:PEROZO VAZQUEZ, SANDRA MARIA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:MARIA
Last Name:PEROZO VAZQUEZ
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 1:6689 E 129TH ST S
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-2503
Mailing Address - Country:US
Mailing Address - Phone:832-991-2555
Mailing Address - Fax:
Practice Address - Street 1:9607 E 95TH CT S
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5839
Practice Address - Country:US
Practice Address - Phone:918-288-0818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0881223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics