Provider Demographics
NPI:1184698599
Name:SANFORD, RICHARD A (DDS,FAGD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:SANFORD
Suffix:
Gender:M
Credentials:DDS,FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 SIBLEY ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2975
Mailing Address - Country:US
Mailing Address - Phone:651-224-6824
Mailing Address - Fax:651-224-3226
Practice Address - Street 1:405 SIBLEY ST
Practice Address - Street 2:SUITE 240
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2975
Practice Address - Country:US
Practice Address - Phone:651-224-6824
Practice Address - Fax:651-224-3226
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN73521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT790449OtherUNITED CONCORDIA
MN27788SAOtherBLUE CROSS BLUE SHIELD