Provider Demographics
NPI:1467529024
Name:BRECKLEY, SEAN HARRIS (DMD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:HARRIS
Last Name:BRECKLEY
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 1:1767 EDGEBORO DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-7338
Mailing Address - Country:US
Mailing Address - Phone:770-919-2014
Mailing Address - Fax:
Practice Address - Street 1:5255 STILESBORO RD NW
Practice Address - Street 2:SUITE 150
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-7737
Practice Address - Country:US
Practice Address - Phone:770-794-3332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013049122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist