Healthcare Provider Details

I. General information

NPI: 1417927377
Provider Name (Legal Business Name): JILL ELISABETH SANDERS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5979 DESERT STORM AVE
FORT CAMPBELL KY
42223-5514
US

IV. Provider business mailing address

112 WATER WOOD DR
CLARKSVILLE TN
37043-7236
US

V. Phone/Fax

Practice location:
  • Phone: 270-412-2787
  • Fax:
Mailing address:
  • Phone: 706-951-1440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0021322
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number21322
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: