MEDICARE: SANDEFER PREMIER DENTAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679922033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANDEFER PREMIER DENTAL, LLC

Provider Business Mailing Address
First Line	:	1291 FLORIDA AVE SW
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70726-4635
Country	:	US
Telephone Number	:	225-664-4121
Fax Number	:	225-664-7774

Provider Business Practice Location Address
First Line	:	1291 FLORIDA AVE SW
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70726-4635
Country	:	US
Telephone Number	:	225-664-4121
Fax Number	:	225-664-7774

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CLINT NATHAN SANDEFER
Credential	:	D.D.S
Telephone Number	:	225-664-4121

Provider Enumeration Date	:	06/07/2016
Last Update Date	:	06/07/2016

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