Healthcare Provider Details

I. General information

NPI: 1124029665
Provider Name (Legal Business Name): COLLIN B SANFORD D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 DALE RD
AVON CT
06001-3612
US

IV. Provider business mailing address

44 DALE RD
AVON CT
06001-3676
US

V. Phone/Fax

Practice location:
  • Phone: 860-677-6405
  • Fax: 860-677-1189
Mailing address:
  • Phone: 860-677-6405
  • Fax: 860-677-1189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number020005127
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: