Provider Demographics
NPI:1710553367
Name:SANDOVAL, MARIA KAY (RDH)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:KAY
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9323 MENCHACA RD APT 921
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-6253
Mailing Address - Country:US
Mailing Address - Phone:765-610-7797
Mailing Address - Fax:
Practice Address - Street 1:9323 MENCHACA RD APT 921
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-6253
Practice Address - Country:US
Practice Address - Phone:765-610-7797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17618124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX17618OtherDENTAL HYGIENE LICENSE NUMBER