Healthcare Provider Details

I. General information

NPI: 1629186028
Provider Name (Legal Business Name): JEFF BEAL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 DIADEM
SAN ANTONIO TX
78219
US

IV. Provider business mailing address

3901 DIADEM
SAN ANTONIO TX
78219
US

V. Phone/Fax

Practice location:
  • Phone: 210-661-8541
  • Fax: 210-661-8582
Mailing address:
  • Phone: 210-661-8541
  • Fax: 210-661-8582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13586
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: