Provider Demographics
NPI:1396108296
Name:SANDESARA, POOJA (DMD)
Entity type:Individual
Prefix:
First Name:POOJA
Middle Name:
Last Name:SANDESARA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11215 E STATE ROAD 70
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-9410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11215 E STATE ROAD 70
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202
Practice Address - Country:US
Practice Address - Phone:973-757-0490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2018-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN221381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice