Provider Demographics
NPI:1598829848
Name:CHURCHMAN, MARY SEALE (DDS)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SEALE
Last Name:CHURCHMAN
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 1:3632 COMMON ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607
Mailing Address - Country:US
Mailing Address - Phone:337-478-4022
Mailing Address - Fax:337-478-4017
Practice Address - Street 1:3632 COMMON ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-1744
Practice Address - Country:US
Practice Address - Phone:337-478-4022
Practice Address - Fax:337-478-4017
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA56621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice