Provider Demographics
NPI:1811542475
Name:SANFORD, DAVID II
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SANFORD
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-9102
Mailing Address - Country:US
Mailing Address - Phone:217-228-0131
Mailing Address - Fax:
Practice Address - Street 1:1451 COTTLEVILLE PKWY
Practice Address - Street 2:
Practice Address - City:COTTLEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63376-3564
Practice Address - Country:US
Practice Address - Phone:636-447-6404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019032330122300000X
MO20190434221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist