Healthcare Provider Details

I. General information

NPI: 1851595433
Provider Name (Legal Business Name): JACK MONROE NEAGLE JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 06/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 W WHITE OAK TER SUITE C
CONROE TX
77304-3590
US

IV. Provider business mailing address

1805 W WHITE OAK TER SUITE C
CONROE TX
77304-3590
US

V. Phone/Fax

Practice location:
  • Phone: 936-539-2980
  • Fax: 936-539-2969
Mailing address:
  • Phone: 936-539-2980
  • Fax: 936-539-2969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number22205 DENTAL
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: