Provider Demographics
NPI:1629588165
Name:SEALY KID'S DENTISTRY
Entity Type:Organization
Organization Name:SEALY KID'S DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:B
Authorized Official - Last Name:ZBORIL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:979-885-4856
Mailing Address - Street 1:2355 HIGHWAY 36 S
Mailing Address - Street 2:
Mailing Address - City:SEALY
Mailing Address - State:TX
Mailing Address - Zip Code:77474-4224
Mailing Address - Country:US
Mailing Address - Phone:979-987-6030
Mailing Address - Fax:979-476-2035
Practice Address - Street 1:2355 HIGHWAY 36 S
Practice Address - Street 2:
Practice Address - City:SEALY
Practice Address - State:TX
Practice Address - Zip Code:77474-4224
Practice Address - Country:US
Practice Address - Phone:979-987-6030
Practice Address - Fax:979-476-2035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX307281223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX350561201Medicaid