Provider Demographics
NPI:1427390491
Name:SANFORD FAMILT DENTAL, LLC
Entity Type:Organization
Organization Name:SANFORD FAMILT DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-324-1345
Mailing Address - Street 1:11 DAIGLE LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-4173
Mailing Address - Country:US
Mailing Address - Phone:207-324-1345
Mailing Address - Fax:
Practice Address - Street 1:11 DAIGLE LN
Practice Address - Street 2:SUITE A
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-4173
Practice Address - Country:US
Practice Address - Phone:207-324-1345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN4290261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental