Provider Demographics
NPI:1720413271
Name:SOUTHERN OAKS DENTAL CLINIC
Entity Type:Organization
Organization Name:SOUTHERN OAKS DENTAL CLINIC
Other - Org Name:SOUTHERN OAKS DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSHUA
Authorized Official - Last Name:SEALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-835-6257
Mailing Address - Street 1:2627 CALDER ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1962
Mailing Address - Country:US
Mailing Address - Phone:409-835-6257
Mailing Address - Fax:409-835-6258
Practice Address - Street 1:2627 CALDER ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1962
Practice Address - Country:US
Practice Address - Phone:409-835-6257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-03
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty