Healthcare Provider Details

I. General information

NPI: 1023956406
Provider Name (Legal Business Name): STANFORD SORENSEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 S 10TH ST
COOS BAY OR
97420-4623
US

IV. Provider business mailing address

295 S 10TH ST
COOS BAY OR
97420-4623
US

V. Phone/Fax

Practice location:
  • Phone: 541-269-5353
  • Fax:
Mailing address:
  • Phone: 541-269-5353
  • Fax: 541-266-0933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD12320
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: