Provider Demographics
NPI:1124115050
Name:SANDERS, ERIC A (DDS)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:A
Last Name:SANDERS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5912
Mailing Address - Country:US
Mailing Address - Phone:337-433-5437
Mailing Address - Fax:337-433-3271
Practice Address - Street 1:2620 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5912
Practice Address - Country:US
Practice Address - Phone:337-433-5437
Practice Address - Fax:337-433-3271
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA47341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1847348Medicaid