Basic Information
| Provider Information | |||||||||
| NPI: | 1700393998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENNER | ||||||||
| FirstName: | SANDY | ||||||||
| MiddleName: | GAIL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MACHOLL | ||||||||
| OtherFirstName: | SANDY | ||||||||
| OtherMiddleName: | GAIL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RDH | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 670 9TH ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955216249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 550 E WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955318160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074654636 | ||||||||
| FaxNumber: | 7074656070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2018 | ||||||||
| LastUpdateDate: | 03/21/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 31737 | CA | Y | Dental Providers | Dental Hygienist |
No ID Information.