MEDICARE: SEAN HADDOW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	2901602200	MI

General Provider Information

NPI Number	:	1720847064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SEAN HADDOW

Provider Business Mailing Address
First Line	:	35888 CONNECTICUT DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-4936
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4216 24TH AVE STE 100
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-4083
Country	:	US
Telephone Number	:	810-984-8669
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2024
Last Update Date	:	06/10/2024

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Directions to “ SEAN HADDOW ” Practice Location

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