Healthcare Provider Details

I. General information

NPI: 1710199682
Provider Name (Legal Business Name): SANDRA ANNE SHOSTAD DMD, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5353 MAIN ST
WILLIAMSVILLE NY
14221-5337
US

IV. Provider business mailing address

5353 MAIN ST
WILLIAMSVILLE NY
14221-5337
US

V. Phone/Fax

Practice location:
  • Phone: 716-634-4121
  • Fax: 716-634-7857
Mailing address:
  • Phone: 716-634-4121
  • Fax: 716-634-7857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number040981
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: