=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467046706
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEALE B2 INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2021
-----------------------------------------------------
Last Update Date | 02/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2155 DOWLEN RD
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77706-2534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-861-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2401 E RANDOL MILL RD
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76011-6349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-809-4865
-----------------------------------------------------
Fax | 682-626-1824
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | TEE SEMERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-809-4865
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------