MEDICARE: JAY CASTLE DDS

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	4175	AR
2	122300000X	Dentist	33979	TX

General Provider Information

NPI Number	:	1508396037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAY CASTLE DDS

Provider Business Mailing Address
First Line	:	3210 RICHMOND RD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-0702
Country	:	US
Telephone Number	:	903-832-3146
Fax Number	:	903-838-2579

Provider Business Practice Location Address
First Line	:	3210 RICHMOND RD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503
Country	:	US
Telephone Number	:	903-832-3146
Fax Number	:	903-838-2579

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2017
Last Update Date	:	07/23/2018

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