=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871584607
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | C ELAM SCULL III DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 N MILAM ST
-----------------------------------------------------
City | SEGUIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78155-5514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-379-8722
-----------------------------------------------------
Fax | 830-379-8728
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 309 N MILAM ST
-----------------------------------------------------
City | SEGUIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78155-5514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-379-8722
-----------------------------------------------------
Fax | 830-379-8728
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT ORTHODONTIST
-----------------------------------------------------
Name | DR. CHARLES ELAM SCULL III
-----------------------------------------------------
Credential | DDS MS
-----------------------------------------------------
Telephone | 830-379-8722
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------