Provider Demographics
NPI:1376977116
Name:SANFORD, NICHOLAS ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ROBERT
Last Name:SANFORD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:NICK
Other - Middle Name:
Other - Last Name:SANFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:101 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAMPTON
Mailing Address - State:IA
Mailing Address - Zip Code:50659-1108
Mailing Address - Country:US
Mailing Address - Phone:641-394-2137
Mailing Address - Fax:641-394-2138
Practice Address - Street 1:101 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:NEW HAMPTON
Practice Address - State:IA
Practice Address - Zip Code:50659-1108
Practice Address - Country:US
Practice Address - Phone:641-394-2137
Practice Address - Fax:641-394-2138
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1223G0001X122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist