Healthcare Provider Details

I. General information

NPI: 1811542475
Provider Name (Legal Business Name): DAVID SANFORD II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 COTTLEVILLE PKWY
COTTLEVILLE MO
63376-3564
US

IV. Provider business mailing address

407 S 48TH ST
QUINCY IL
62305-9102
US

V. Phone/Fax

Practice location:
  • Phone: 636-447-6404
  • Fax:
Mailing address:
  • Phone: 217-228-0131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019032330
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2019043422
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: