Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 0401415596 | VA |
N | 1223S0112X | Oral and Maxillofacial Surgeon | 2901022038 | MI |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 0438000372 | VA |
NPI | 1083901425 |
---|---|
Provider Name | Dr. Sean E Pack |
First Address | Glen Allen, VA 23059-5666 |
Second Address | Mechanicsville, VA 23116 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2011 |
Last Update Date | 02/08/2018 |