Provider Demographics
NPI:1689836439
Name:BRASSEALE, BEAU JOHN (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:BEAU
Middle Name:JOHN
Last Name:BRASSEALE
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 WILKINSON TRCE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-2483
Mailing Address - Country:US
Mailing Address - Phone:270-904-4404
Mailing Address - Fax:
Practice Address - Street 1:901 WILKINSON TRCE
Practice Address - Street 2:SUITE #2
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-2483
Practice Address - Country:US
Practice Address - Phone:270-904-4404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011193A1223G0001X
KY91021223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice