Provider Demographics
NPI:1831829100
Name:SEALOCK, BRYCE D (OD)
Entity type:Individual
Prefix:
First Name:BRYCE
Middle Name:D
Last Name:SEALOCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4455 HIGHWAY 169 N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-2897
Mailing Address - Country:US
Mailing Address - Phone:763-559-7358
Mailing Address - Fax:763-559-6010
Practice Address - Street 1:4455 HIGHWAY 169 N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-2897
Practice Address - Country:US
Practice Address - Phone:763-559-7358
Practice Address - Fax:763-559-6010
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3797152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist