Healthcare Provider Details

I. General information

NPI: 1437649431
Provider Name (Legal Business Name): SEAN ECCLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7009 LEE PARK RD
MECHANICSVILLE VA
23111
US

IV. Provider business mailing address

PO BOX 71930
RICHMOND VA
23255-1930
US

V. Phone/Fax

Practice location:
  • Phone: 804-354-1600
  • Fax: 804-746-4158
Mailing address:
  • Phone: 804-354-1600
  • Fax: 804-354-1607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number0442000334
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0442000334
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: