Provider Demographics
NPI:1972241446
Name:SANDOVAL, EDUARDO (DDS)
Entity type:Individual
Prefix:DR
First Name:EDUARDO
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1398 N AZUSA AVE
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-2036
Mailing Address - Country:US
Mailing Address - Phone:626-422-8164
Mailing Address - Fax:
Practice Address - Street 1:8325 HAVEN AVE STE 130
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3894
Practice Address - Country:US
Practice Address - Phone:909-989-3566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107452122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist