Provider Demographics
NPI:1346561743
Name:ALTENBACH, SEAN M (DMD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:M
Last Name:ALTENBACH
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 1:1136 KINGS RD
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-3214
Mailing Address - Country:US
Mailing Address - Phone:904-422-4150
Mailing Address - Fax:
Practice Address - Street 1:8841 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4244
Practice Address - Country:US
Practice Address - Phone:904-448-0441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-20
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN189881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice