Provider Demographics
NPI:1407167034
Name:SAND, JONATHAN CALEB (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:CALEB
Last Name:SAND
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 1:130 W 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLDREGE
Mailing Address - State:NE
Mailing Address - Zip Code:68949-1270
Mailing Address - Country:US
Mailing Address - Phone:308-995-8666
Mailing Address - Fax:308-995-2759
Practice Address - Street 1:130 W 14TH AVE
Practice Address - Street 2:
Practice Address - City:HOLDREGE
Practice Address - State:NE
Practice Address - Zip Code:68949-1270
Practice Address - Country:US
Practice Address - Phone:308-995-8666
Practice Address - Fax:308-995-2759
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE68791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025699000Medicaid