Provider Demographics
NPI:1427070531
Name:SEABOLT, RUSSELL A (DMD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:A
Last Name:SEABOLT
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:PO BOX 640
Mailing Address - Street 2:21 KIMBERLY LANE
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-0011
Mailing Address - Country:US
Mailing Address - Phone:706-632-6800
Mailing Address - Fax:706-632-6802
Practice Address - Street 1:21 KIMBERLY LANE
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513
Practice Address - Country:US
Practice Address - Phone:706-632-6800
Practice Address - Fax:706-632-6802
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA108271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice