Provider Demographics
NPI:1053857367
Name:MERRILY M SANDFORD, DDS, PA
Entity Type:Organization
Organization Name:MERRILY M SANDFORD, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MERRILY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SANDFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-263-8284
Mailing Address - Street 1:2303 RANCH ROAD 620 S
Mailing Address - Street 2:SUITE 140
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-6219
Mailing Address - Country:US
Mailing Address - Phone:512-263-8284
Mailing Address - Fax:
Practice Address - Street 1:2303 RANCH ROAD 620 S
Practice Address - Street 2:SUITE 140
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-6219
Practice Address - Country:US
Practice Address - Phone:512-263-8284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERRILY SANDFORD, DDS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-10
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18565261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental