Provider Demographics
NPI:1154466258
Name:SANDEFER, CLINT N (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLINT
Middle Name:N
Last Name:SANDEFER
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 1:1291 FLORIDA AVE SW
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-4635
Mailing Address - Country:US
Mailing Address - Phone:225-664-4121
Mailing Address - Fax:225-664-7774
Practice Address - Street 1:1291 FLORIDA AVE SW
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-4635
Practice Address - Country:US
Practice Address - Phone:225-664-4121
Practice Address - Fax:225-664-7774
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA56581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice