Provider Demographics
NPI:1124134689
Name:BEELER, JACK E (DDS, PC)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:E
Last Name:BEELER
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 N VIRGINIA ST
Mailing Address - Street 2:P.O. BOX 12
Mailing Address - City:PORT LAVACA
Mailing Address - State:TX
Mailing Address - Zip Code:77979-3021
Mailing Address - Country:US
Mailing Address - Phone:361-552-6814
Mailing Address - Fax:
Practice Address - Street 1:621 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979-3021
Practice Address - Country:US
Practice Address - Phone:361-552-6814
Practice Address - Fax:361-552-8193
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX831716OtherUNITED CONCORDIA