Healthcare Provider Details

I. General information

NPI: 1245200104
Provider Name (Legal Business Name): JERROD LYNN SANDERS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5979 DESERT STORM AVE
FORT CAMPBELL KY
42223-5514
US

IV. Provider business mailing address

9900 LINCON ST FL 2 HQS USA DENTAC
JOINT BASE LEWIS MCCHORD WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 270-412-8563
  • Fax:
Mailing address:
  • Phone: 253-968-4029
  • Fax: 253-968-5919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0021321
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number21321
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: