Healthcare Provider Details

I. General information

NPI: 1659708055
Provider Name (Legal Business Name): JASPER DENTAL EMPORIUM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2013
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 W RR 255
BROOKELAND TX
75931-6412
US

IV. Provider business mailing address

PO BOX 5210
SAM RAYBURN TX
75951-6412
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

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