1780643130 NPI number — DR. RICHARD A BEATTY DMD

Table of content: DR. RICHARD A BEATTY DMD (NPI 1780643130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780643130 NPI number — DR. RICHARD A BEATTY DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEATTY
Provider First Name:
RICHARD
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780643130
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
259 ALLEGHENY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JERSEY SHORE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17740-1422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-398-4266
Provider Business Mailing Address Fax Number:
570-398-2871

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
259 ALLEGHENY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JERSEY SHORE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17740-1422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-398-4266
Provider Business Practice Location Address Fax Number:
570-398-2871
Provider Enumeration Date:
03/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DS020157L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DS020157L . This is a "STATE LICENSE #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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