Provider Demographics
NPI:1932242815
Name:SANFORD, PAULETTE RAE (DDS)
Entity Type:Individual
Prefix:
First Name:PAULETTE
Middle Name:RAE
Last Name:SANFORD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 STAR MDW
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-2512
Mailing Address - Country:US
Mailing Address - Phone:512-256-9747
Mailing Address - Fax:
Practice Address - Street 1:4221 BENNER STE 200
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-2221
Practice Address - Country:US
Practice Address - Phone:512-256-9747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA 412131223G0001X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment