Provider Demographics
NPI:1497382113
Name:SEAGRAVES, AMY LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:LYNN
Last Name:SEAGRAVES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 WASHINGTON BLVD APT 1S
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3945
Mailing Address - Country:US
Mailing Address - Phone:330-360-4241
Mailing Address - Fax:
Practice Address - Street 1:4233 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2623
Practice Address - Country:US
Practice Address - Phone:708-636-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190325221223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty