MEDICARE: DR. CLINT N SANDEFER D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5658	LA

General Provider Information

NPI Number	:	1154466258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLINT N SANDEFER D.D.S

Provider Business Mailing Address
First Line	:	1291 FLORIDA AVE SW
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70726-4635
Country	:	US
Telephone Number	:	225-664-4121
Fax Number	:	225-664-7774

Provider Business Practice Location Address
First Line	:	1291 FLORIDA AVE SW
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70726-4635
Country	:	US
Telephone Number	:	225-664-4121
Fax Number	:	225-664-7774

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	07/08/2007

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