Healthcare Provider Details

I. General information

NPI: 1023028297
Provider Name (Legal Business Name): SANFORD ROBERT ROSENBERG D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 VILLAGE WAY
ORANGE PARK FL
32073-5263
US

IV. Provider business mailing address

1725 VILLAGE WAY
ORANGE PARK FL
32073-5263
US

V. Phone/Fax

Practice location:
  • Phone: 904-264-6500
  • Fax: 904-264-0995
Mailing address:
  • Phone: 904-264-6500
  • Fax: 904-264-0995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN 6981
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: