MEDICARE: DR. JACK E. BEELER DDS, PC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	10567	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	831716	OTHER	TX	UNITED CONCORDIA

General Provider Information

NPI Number	:	1124134689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK E. BEELER DDS, PC.

Provider Business Mailing Address
First Line	:	621 N VIRGINIA ST
Second Line	:	P.O. BOX 12
City	:	PORT LAVACA
State	:	TX
Zip	:	77979-3021
Country	:	US
Telephone Number	:	361-552-6814
Fax Number	:

Provider Business Practice Location Address
First Line	:	621 N VIRGINIA ST
Second Line	:
City	:	PORT LAVACA
State	:	TX
Zip	:	77979-3021
Country	:	US
Telephone Number	:	361-552-6814
Fax Number	:	361-552-8193

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	04/12/2026

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