Provider Demographics
NPI:1669831004
Name:SANTOS, SANDRA M (DMD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:M
Last Name:SANTOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 KIRTLEY DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-2255
Mailing Address - Country:US
Mailing Address - Phone:813-957-5913
Mailing Address - Fax:
Practice Address - Street 1:11478 S US HWY 301 S
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569
Practice Address - Country:US
Practice Address - Phone:813-957-5913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN223431223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty