Provider Demographics
NPI:1487498721
Name:SANDERS, ANDREW (DMD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:SANDERS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4549 CASTLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8799
Mailing Address - Country:US
Mailing Address - Phone:817-791-3322
Mailing Address - Fax:
Practice Address - Street 1:1156 JOHN SIMS PKWY E
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2204
Practice Address - Country:US
Practice Address - Phone:850-252-1696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL12345671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program