Healthcare Provider Details

I. General information

NPI: 1942839410
Provider Name (Legal Business Name): DR. DARIUS WILLIAM SANFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W PONCE DE LEON AVE
DECATUR GA
30030-2400
US

IV. Provider business mailing address

310 ELLIE LN
MCDONOUGH GA
30252-4207
US

V. Phone/Fax

Practice location:
  • Phone: 404-381-1840
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN122527
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: