Provider Demographics
NPI:1558374132
Name:BYRON P SANSOM A DENTAL CORPORATION
Entity Type:Organization
Organization Name:BYRON P SANSOM A DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:SANSOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-934-3730
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:PMB #389
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-0100
Mailing Address - Country:US
Mailing Address - Phone:760-934-3730
Mailing Address - Fax:760-934-3732
Practice Address - Street 1:452 OLD MAMMOTH RD.
Practice Address - Street 2:SUITE L
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546
Practice Address - Country:US
Practice Address - Phone:760-934-3730
Practice Address - Fax:760-934-3732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33366282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural