MEDICARE: SE PROFESSIONAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1174934236
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SE PROFESSIONAL

Provider Business Mailing Address
First Line	:	1127 S MAIN ST
Second Line	:
City	:	GRAPEVINE
State	:	TX
Zip	:	76051-7533
Country	:	US
Telephone Number	:	972-377-4477
Fax Number	:

Provider Business Practice Location Address
First Line	:	5858 W MAIN ST
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75033-4193
Country	:	US
Telephone Number	:	972-377-4477
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. JARED BRUGGEMAN
Credential	:
Telephone Number	:	817-912-2982

Provider Enumeration Date	:	05/12/2014
Last Update Date	:	05/12/2014

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