Provider Demographics
NPI:1578056172
Name:SEAGER, BEAU EDWARD
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:EDWARD
Last Name:SEAGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 W 2230 N STE 103
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-7581
Mailing Address - Country:US
Mailing Address - Phone:801-854-8081
Mailing Address - Fax:
Practice Address - Street 1:247 W 2230 N STE 103
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-7581
Practice Address - Country:US
Practice Address - Phone:801-374-2405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341201223G0001X
UT12149027-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice