Provider Demographics
NPI:1740411792
Name:SANDERS DENTAL
Entity Type:Organization
Organization Name:SANDERS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:HART
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:985-876-5430
Mailing Address - Street 1:761 W TUNNEL BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-5545
Mailing Address - Country:US
Mailing Address - Phone:985-876-5430
Mailing Address - Fax:985-876-0455
Practice Address - Street 1:761 W TUNNEL BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-5545
Practice Address - Country:US
Practice Address - Phone:985-876-5430
Practice Address - Fax:985-876-0455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA46481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1846481Medicaid