Provider Demographics
NPI:1447489273
Name:SANDBERG, KENNETH GUY (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:GUY
Last Name:SANDBERG
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 1:1310 24TH AVE S
Mailing Address - Street 2:DENTAL (0160)
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37212-2637
Mailing Address - Country:US
Mailing Address - Phone:615-873-7120
Mailing Address - Fax:
Practice Address - Street 1:1310 24TH AVE S
Practice Address - Street 2:DENTAL (0160)
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-2637
Practice Address - Country:US
Practice Address - Phone:615-873-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX248241223G0001X
TNDS92401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice