Provider Demographics
NPI:1942214358
Name:PHELAN, SEAN STACY (DDS)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:STACY
Last Name:PHELAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 JUAN TABO BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-3306
Mailing Address - Country:US
Mailing Address - Phone:505-237-2273
Mailing Address - Fax:505-323-9294
Practice Address - Street 1:2010 JUAN TABO BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-3306
Practice Address - Country:US
Practice Address - Phone:505-237-2273
Practice Address - Fax:505-323-9294
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD27121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM413131OtherUNITED CONCORDIA