=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225558869
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAMILAH SANFORD, D.D.S., INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2017
-----------------------------------------------------
Last Update Date | 06/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2830 PINOLE VALLEY RD STE C
-----------------------------------------------------
City | PINOLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94564-1453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-334-1593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 334 WILDROSE CIR
-----------------------------------------------------
City | PINOLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94564-2304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KAMILAH SANFORD
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 510-334-1593
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------