Healthcare Provider Details

I. General information

NPI: 1538102785
Provider Name (Legal Business Name): JOHNNY BOYD SANDIFER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 N ORANGE BLOSSOM TRL
ORLANDO FL
32805-1612
US

IV. Provider business mailing address

710 LAKE CATHERINE DR
MAITLAND FL
32751-5539
US

V. Phone/Fax

Practice location:
  • Phone: 407-428-1672
  • Fax:
Mailing address:
  • Phone: 843-270-2106
  • Fax: 843-792-7809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN17316
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: