MEDICARE: DEREK W SANDERS RDH

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	124Q00000X	Dental Hygienist	7135	TN

General Provider Information

NPI Number	:	1568016053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK W SANDERS RDH

Provider Business Mailing Address
First Line	:	136 IRISH OAKS DR
Second Line	:
City	:	PORTLAND
State	:	TN
Zip	:	37148-2249
Country	:	US
Telephone Number	:	615-388-6841
Fax Number	:

Provider Business Practice Location Address
First Line	:	2711 FOSTER AVE
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37210-5307
Country	:	US
Telephone Number	:	615-227-3000
Fax Number	:	615-515-5775

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

Provider Enumeration Date	:	08/01/2019
Last Update Date	:	08/01/2019

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