Provider Demographics
NPI:1962992487
Name:SANDOVAL, BONNIE
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:SANDOVAL
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 1:7005 N CHESTNUT AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-0348
Mailing Address - Country:US
Mailing Address - Phone:155-929-9394
Mailing Address - Fax:559-299-7880
Practice Address - Street 1:7005 N CHESTNUT AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-0348
Practice Address - Country:US
Practice Address - Phone:155-929-9394
Practice Address - Fax:559-299-7880
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA80298126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant