Healthcare Provider Details

I. General information

NPI: 1760939888
Provider Name (Legal Business Name): JASPER DENTAL EMPORIUM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 RECREATIONAL ROAD 255 WEST
BROOKELAND TX
75931
US

IV. Provider business mailing address

3303 RECREATIONAL ROAD 255 WEST
BROOKELAND TX
75931
US

V. Phone/Fax

Practice location:
  • Phone: 409-698-8800
  • Fax: 409-698-8801
Mailing address:
  • Phone: 409-698-8800
  • Fax: 409-698-8801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number15204
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22917
License Number StateTX

VIII. Authorized Official

Name: DR. JOHN JOSHUA SEALE
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 409-698-8800