Provider Demographics
NPI:1790750586
Name:PRINCE, SANDFORD W (DMD)
Entity Type:Individual
Prefix:DR
First Name:SANDFORD
Middle Name:W
Last Name:PRINCE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:MR
Other - First Name:SANFORD
Other - Middle Name:
Other - Last Name:PRINCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:2306 KNOB CREEK ROAD #108
Mailing Address - Street 2:KNOB CREEK ORAL CLINIC
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604
Mailing Address - Country:US
Mailing Address - Phone:423-467-5009
Mailing Address - Fax:423-467-5009
Practice Address - Street 1:2306 KNOB CREEK ROAD #108
Practice Address - Street 2:KNOB CREEK ORAL CLINIC
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-467-5009
Practice Address - Fax:423-467-5009
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QS0112X
TNDS00000096471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN12683544OtherCAQH
TN465705259OtherTENNESSEE
TN465705259OtherTENNESSEE