=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700632510
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JULEE TAE DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2024
-----------------------------------------------------
Last Update Date | 04/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1420 S MAIN ST
-----------------------------------------------------
City | WEATHERFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76086-5531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-350-0777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1420 S MAIN ST
-----------------------------------------------------
City | WEATHERFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76086-5531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-350-0777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JULEE TAE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-380-2264
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------