Healthcare Provider Details

I. General information

NPI: 1942371695
Provider Name (Legal Business Name): SANFORD JAY FENTON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 UNION AVE S 217 B
MEMPHIS TN
38163-0001
US

IV. Provider business mailing address

8658 STABLEMILL LN
CORDOVA TN
38016-6154
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-6206
  • Fax: 901-448-6249
Mailing address:
  • Phone: 870-733-3854
  • Fax: 870-733-3851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS0000007119
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3314
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: