Provider Demographics
NPI:1558654012
Name:GOOLSBY, SEAN PATRICK (DDS)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:PATRICK
Last Name:GOOLSBY
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:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-0399
Mailing Address - Country:US
Mailing Address - Phone:651-257-2720
Mailing Address - Fax:651-257-8752
Practice Address - Street 1:12745 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045-9585
Practice Address - Country:US
Practice Address - Phone:651-257-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND131521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice