Provider Demographics
NPI:1912078478
Name:OH, SANDRA (DMD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:OH
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 1:3650 BAXLEY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4501
Mailing Address - Country:US
Mailing Address - Phone:678-373-3225
Mailing Address - Fax:678-373-3225
Practice Address - Street 1:3650 BAXLEY RIDGE DR
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4501
Practice Address - Country:US
Practice Address - Phone:770-630-9141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0133791223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA672066157BMedicaid