Provider Demographics
NPI:1275747651
Name:SELLECK, MICHAEL JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:SELLECK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 MORAGA RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-4584
Mailing Address - Country:US
Mailing Address - Phone:925-283-0338
Mailing Address - Fax:925-283-0360
Practice Address - Street 1:935 MORAGA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-4584
Practice Address - Country:US
Practice Address - Phone:925-283-0338
Practice Address - Fax:925-283-0360
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA245021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20-2381272OtherTAX