Provider Demographics
NPI:1659708055
Name:JASPER DENTAL EMPORIUM
Entity Type:Organization
Organization Name:JASPER DENTAL EMPORIUM
Other - Org Name:RAYBURN GENERAL DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSHUA
Authorized Official - Last Name:SEALE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:409-698-8800
Mailing Address - Street 1:PO BOX 5210
Mailing Address - Street 2:
Mailing Address - City:SAM RAYBURN
Mailing Address - State:TX
Mailing Address - Zip Code:75951-6412
Mailing Address - Country:US
Mailing Address - Phone:409-698-8800
Mailing Address - Fax:
Practice Address - Street 1:3303 W RR 255
Practice Address - Street 2:
Practice Address - City:BROOKELAND
Practice Address - State:TX
Practice Address - Zip Code:75931-6412
Practice Address - Country:US
Practice Address - Phone:409-698-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty