Provider Demographics
NPI:1396039640
Name:SEAGO, KRISTINA MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:MARIE
Last Name:SEAGO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 LOCHMOOR BLVD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1750
Mailing Address - Country:US
Mailing Address - Phone:313-530-7813
Mailing Address - Fax:
Practice Address - Street 1:30207 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082-2612
Practice Address - Country:US
Practice Address - Phone:313-530-7813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020628122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist