Provider Demographics
NPI:1164003935
Name:SANFORD, JAMES EDWARD
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EDWARD
Last Name:SANFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W SPRUCE ST APT C
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-5555
Mailing Address - Country:US
Mailing Address - Phone:619-920-6799
Mailing Address - Fax:
Practice Address - Street 1:105 W SPRUCE ST APT C
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5555
Practice Address - Country:US
Practice Address - Phone:619-920-6799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA262281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice