Healthcare Provider Details

I. General information

NPI: 1043648199
Provider Name (Legal Business Name): JOHN H. CASE D.D.S., M.S., P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1326 MEMORIAL DR
BRYAN TX
77802-5215
US

IV. Provider business mailing address

1326 MEMORIAL DR
BRYAN TX
77802-5215
US

V. Phone/Fax

Practice location:
  • Phone: 979-776-8100
  • Fax: 979-776-8123
Mailing address:
  • Phone: 979-776-8100
  • Fax: 979-776-8123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12102
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12102
License Number StateTX

VIII. Authorized Official

Name: DR. JOHN CASE
Title or Position: OWNER
Credential: D.D.S., M.S.
Phone: 979-776-8100