Provider Demographics
NPI:1932776036
Name:SEEGOBIN, KARISSE JOSELLE
Entity Type:Individual
Prefix:
First Name:KARISSE
Middle Name:JOSELLE
Last Name:SEEGOBIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 AGIN WAY
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:KY
Mailing Address - Zip Code:40045-1509
Mailing Address - Country:US
Mailing Address - Phone:502-268-3192
Mailing Address - Fax:
Practice Address - Street 1:25 AGIN WAY
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:KY
Practice Address - Zip Code:40045-1509
Practice Address - Country:US
Practice Address - Phone:502-268-3192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY106651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY10665OtherKY LICENSE
60320595OtherDENTPIN