Healthcare Provider Details

I. General information

NPI: 1427037555
Provider Name (Legal Business Name): ANDRE CHARLES SANTOS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 02/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG H 2005 KNIGHT LANE NAVY MEDICINE SUPPORT COMMAND ATTN:MEDICAL STAFF SVCS
JACKSONVILLE FL
32212-0140
US

IV. Provider business mailing address

8468 GRAY FOX LN
KING GEORGE VA
22485-3571
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-5102
  • Fax: 760-763-6510
Mailing address:
  • Phone: 540-775-5058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401008447
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: