Provider Demographics
NPI:1053090217
Name:SOURIALLE, SARAH (DMD)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:SOURIALLE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SAINT RAPHAEL
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-2761
Mailing Address - Country:US
Mailing Address - Phone:909-732-7487
Mailing Address - Fax:
Practice Address - Street 1:3014 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-5805
Practice Address - Country:US
Practice Address - Phone:312-291-9283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019034499122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist