Provider Demographics
NPI:1750951836
Name:SEBASTIAN, NEETHU (DMD)
Entity type:Individual
Prefix:
First Name:NEETHU
Middle Name:
Last Name:SEBASTIAN
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 1:716 BALBOA CT
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-5008
Mailing Address - Country:US
Mailing Address - Phone:803-318-4288
Mailing Address - Fax:
Practice Address - Street 1:4815 BEREWICK TOWN CENTER DR STE J
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-6733
Practice Address - Country:US
Practice Address - Phone:704-800-0252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC123111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice