Healthcare Provider Details

I. General information

NPI: 1841250743
Provider Name (Legal Business Name): SEAN D. WALCOTT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 GRASSLANDS BLVD STE 200
LAKELAND FL
33803-5488
US

IV. Provider business mailing address

1301 GRASSLANDS BLVD STE 200
LAKELAND FL
33803-5488
US

V. Phone/Fax

Practice location:
  • Phone: 813-885-6555
  • Fax: 863-647-3514
Mailing address:
  • Phone: 813-885-6555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN16473
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: