Healthcare Provider Details

I. General information

NPI: 1598735730
Provider Name (Legal Business Name): KYLE T SANDERS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3664 CLUB DR SUITE 105
LAWRENCEVILLE GA
30044-2961
US

IV. Provider business mailing address

2500 MARKETPLACE DRIVE SUITE 122
WACO TX
76711
US

V. Phone/Fax

Practice location:
  • Phone: 770-279-7987
  • Fax: 770-279-8951
Mailing address:
  • Phone: 404-488-2741
  • Fax: 678-662-5795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number11929
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number25056
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: