Provider Demographics
NPI:1477664100
Name:SANDERS, SAMUEL BRET (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:BRET
Last Name:SANDERS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 LAMY LN
Mailing Address - Street 2:SUITE C
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3804
Mailing Address - Country:US
Mailing Address - Phone:318-323-9500
Mailing Address - Fax:318-323-9888
Practice Address - Street 1:1507 LAMY LN
Practice Address - Street 2:SUITE C
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3804
Practice Address - Country:US
Practice Address - Phone:318-323-9500
Practice Address - Fax:318-323-9888
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA46541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1846546Medicaid