Healthcare Provider Details

I. General information

NPI: 1104094226
Provider Name (Legal Business Name): EDWARD A NEUSEL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 02/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E AVENUE G
SILSBEE TX
77656-4141
US

IV. Provider business mailing address

14 PASCAL LN
AUSTIN TX
78746-3203
US

V. Phone/Fax

Practice location:
  • Phone: 409-385-3651
  • Fax:
Mailing address:
  • Phone: 512-382-1406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10828
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: