Provider Demographics
NPI:1780086595
Name:SEALE, MISTY MAE (DMD)
Entity type:Individual
Prefix:DR
First Name:MISTY
Middle Name:MAE
Last Name:SEALE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:135 GOSHEN ROAD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-5546
Mailing Address - Country:US
Mailing Address - Phone:912-499-1133
Mailing Address - Fax:912-348-5806
Practice Address - Street 1:135 GOSHEN ROAD
Practice Address - Street 2:SUITE 205
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-5546
Practice Address - Country:US
Practice Address - Phone:912-499-1133
Practice Address - Fax:912-348-5806
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014852122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist