Provider Demographics
NPI:1568511822
Name:BREY SANFORD, MISTY MICHELLE (DMD)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:MICHELLE
Last Name:BREY SANFORD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:MICHELLE
Other - Last Name:BREY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:2817 VEACH ROAD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303
Mailing Address - Country:US
Mailing Address - Phone:270-684-2463
Mailing Address - Fax:270-684-9449
Practice Address - Street 1:2817 VEACH ROAD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303
Practice Address - Country:US
Practice Address - Phone:270-684-2463
Practice Address - Fax:270-684-9449
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY67381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60067386Medicaid