Basic Information
Provider Information
NPI: 1083029664
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: COLEY
FirstName: SANDRA
MiddleName: M.
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: TAYLOR
OtherFirstName: SANDRA
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 1
Mailing Information
Address1: 1103 KATHRYN RD
Address2:  
City: SILVER SPRING
State: MD
PostalCode: 209042173
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1251 SARATOGA AVE NE
Address2:  
City: WASHINGTON
State: DC
PostalCode: 200181025
CountryCode: US
TelephoneNumber: 2028328818
FaxNumber: 2025488600
Other Information
ProviderEnumerationDate: 06/23/2014
LastUpdateDate: 03/17/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X15574MDY Dental ProvidersDentist 

ID Information
IDTypeStateIssuerDescription
08018440005MD MEDICAID


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