Provider Demographics
NPI:1114150760
Name:SEEBALDT, KELLY ADAIR (DMD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ADAIR
Last Name:SEEBALDT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ELEVENTH AVE.
Mailing Address - Street 2:SUITE D-3
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579
Mailing Address - Country:US
Mailing Address - Phone:850-651-6700
Mailing Address - Fax:850-609-0796
Practice Address - Street 1:1 11TH AVE
Practice Address - Street 2:SUITE D-3
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1324
Practice Address - Country:US
Practice Address - Phone:850-651-6700
Practice Address - Fax:850-609-0796
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 186981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice