MEDICARE: KEVIN ISACC SANDEFER DDS

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	122300000X	Dentist	22261	TX
2	1223G0001X	General Practice Dentistry	22261	TX

General Provider Information

NPI Number	:	1881670966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN ISACC SANDEFER DDS

Provider Business Mailing Address
First Line	:	7703 FLOYD CURL DRIVE, MSC 7914
Second Line	:	DEPT OF COMPREHENSIVE DENTISTRY, UT HEALTH SCIENCE CENT
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3900
Country	:	US
Telephone Number	:	210-567-3456
Fax Number	:	210-567-3443

Provider Business Practice Location Address
First Line	:	7703 FLOYD CURL DRIVE, MSC 7903
Second Line	:	ADVANCED GENERAL DENTISTRY CLINIC, UT HEALTH SCIENCE CE
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3900
Country	:	US
Telephone Number	:	210-567-3456
Fax Number	:	210-567-3443

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

Provider Enumeration Date	:	12/20/2005
Last Update Date	:	12/01/2010

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