Healthcare Provider Details

I. General information

NPI: 1790750586
Provider Name (Legal Business Name): SANDFORD W PRINCE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: SANFORD PRINCE DMD

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2306 KNOB CREEK ROAD #108 KNOB CREEK ORAL CLINIC
JOHNSON CITY TN
37604
US

IV. Provider business mailing address

2306 KNOB CREEK ROAD #108 KNOB CREEK ORAL CLINIC
JOHNSON CITY TN
37604
US

V. Phone/Fax

Practice location:
  • Phone: 423-467-5009
  • Fax: 423-467-5009
Mailing address:
  • Phone: 423-467-5009
  • Fax: 423-467-5009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS0000009647
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: