=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255063400
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANN MARIE SEELBACH DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2022
-----------------------------------------------------
Last Update Date | 08/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3891 E LEAGUE CITY PKWY
-----------------------------------------------------
City | LEAGUE CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77573-1551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-557-7747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1911 MERMAID LN
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77062-6104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-632-7395
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 38768
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------