Provider Demographics
NPI:1437649431
Name:ECCLES, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:ECCLES
Suffix:
Gender:M
Credentials:
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 71930
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23255-1930
Mailing Address - Country:US
Mailing Address - Phone:804-354-1600
Mailing Address - Fax:804-354-1607
Practice Address - Street 1:7009 LEE PARK RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111
Practice Address - Country:US
Practice Address - Phone:804-354-1600
Practice Address - Fax:804-746-4158
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0442000334204E00000X, 1223S0112X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery