Provider Demographics
NPI:1609971969
Name:SELLARS, MIA R (DMD)
Entity Type:Individual
Prefix:MS
First Name:MIA
Middle Name:R
Last Name:SELLARS
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:CLOVER FORK CLINIC
Mailing Address - Street 2:PO BOX 39
Mailing Address - City:EVARTS
Mailing Address - State:KY
Mailing Address - Zip Code:40828-0039
Mailing Address - Country:US
Mailing Address - Phone:606-837-2108
Mailing Address - Fax:606-837-9389
Practice Address - Street 1:CLOVER FORK CLINIC
Practice Address - Street 2:101 CHAD ST
Practice Address - City:EVARTS
Practice Address - State:KY
Practice Address - Zip Code:40828-0039
Practice Address - Country:US
Practice Address - Phone:606-837-2108
Practice Address - Fax:606-837-9389
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6865122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60001864Medicaid