MEDICARE: SHELLEY RENE SANFORD 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	4295	AR

General Provider Information

NPI Number	:	1942795216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLEY RENE SANFORD DDS

Provider Business Mailing Address
First Line	:	2501 CRESTWOOD RD STE 103
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-7615
Country	:	US
Telephone Number	:	501-758-3393
Fax Number	:	501-758-4346

Provider Business Practice Location Address
First Line	:	2501 CRESTWOOD RD STE 103
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-7615
Country	:	US
Telephone Number	:	501-758-3393
Fax Number	:	501-758-4346

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

Provider Enumeration Date	:	06/28/2018
Last Update Date	:	06/28/2018

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