Healthcare Provider Details

I. General information

NPI: 1568521755
Provider Name (Legal Business Name): JERRY SANDERS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 12/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 E RAINFOREST DR
FAYETTEVILLE AR
72703-5385
US

IV. Provider business mailing address

1607 E RAINFOREST DR
FAYETTEVILLE AR
72703-5385
US

V. Phone/Fax

Practice location:
  • Phone: 479-582-0600
  • Fax: 479-443-4630
Mailing address:
  • Phone: 479-582-0600
  • Fax: 479-443-4630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3424
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: