Provider Demographics
NPI:1154540615
Name:SEUBERT, JAN L (DDS)
Entity type:Individual
Prefix:DR
First Name:JAN
Middle Name:L
Last Name:SEUBERT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 W COOK ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-2106
Mailing Address - Country:US
Mailing Address - Phone:608-742-2331
Mailing Address - Fax:608-742-4308
Practice Address - Street 1:260 W COOK ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-2106
Practice Address - Country:US
Practice Address - Phone:608-742-2331
Practice Address - Fax:608-742-4308
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice