Healthcare Provider Details

I. General information

NPI: 1497120612
Provider Name (Legal Business Name): SANDY ROSENBERG DMD PL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2015
Last Update Date: 12/14/2015
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: 904-265-6500
  • Fax: 904-264-0995
Mailing address:
  • Phone: 904-265-6500
  • Fax: 904-264-0995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6981
License Number StateFL

VIII. Authorized Official

Name: DR. SANFORD R ROSENBERG
Title or Position: DENTIST/OWNER
Credential: D.M.D.
Phone: 904-264-6500