Healthcare Provider Details

I. General information

NPI: 1689836439
Provider Name (Legal Business Name): BEAU JOHN BRASSEALE D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 WILKINSON TRCE SUITE #2
BOWLING GREEN KY
42103-2483
US

IV. Provider business mailing address

901 WILKINSON TRCE SUITE #2
BOWLING GREEN KY
42103-2483
US

V. Phone/Fax

Practice location:
  • Phone: 270-904-4404
  • Fax:
Mailing address:
  • Phone: 270-904-4404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number9102
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12011193A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: