Provider Demographics
NPI:1881670966
Name:SANDEFER, KEVIN ISACC (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ISACC
Last Name:SANDEFER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7703 FLOYD CURL DRIVE, MSC 7914
Mailing Address - Street 2:DEPT OF COMPREHENSIVE DENTISTRY, UT HEALTH SCIENCE CENT
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3900
Mailing Address - Country:US
Mailing Address - Phone:210-567-3456
Mailing Address - Fax:210-567-3443
Practice Address - Street 1:7703 FLOYD CURL DRIVE, MSC 7903
Practice Address - Street 2:ADVANCED GENERAL DENTISTRY CLINIC, UT HEALTH SCIENCE CE
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3900
Practice Address - Country:US
Practice Address - Phone:210-567-3456
Practice Address - Fax:210-567-3443
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22261122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D9385Medicare ID - Type Unspecified
TXV06434Medicare UPIN