Provider Demographics
NPI:1033191598
Name:SANANDAJI, KAMRAN (DDS)
Entity Type:Individual
Prefix:
First Name:KAMRAN
Middle Name:
Last Name:SANANDAJI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7937
Mailing Address - Country:US
Mailing Address - Phone:631-968-5995
Mailing Address - Fax:631-968-5996
Practice Address - Street 1:1745 UNION BLVD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7937
Practice Address - Country:US
Practice Address - Phone:631-968-5995
Practice Address - Fax:631-968-5996
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0460791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01660517Medicaid