Provider Demographics
NPI:1003894478
Name:BEATY, DUDLEY C III (DMD)
Entity Type:Individual
Prefix:
First Name:DUDLEY
Middle Name:C
Last Name:BEATY
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-4003
Mailing Address - Country:US
Mailing Address - Phone:843-479-0305
Mailing Address - Fax:
Practice Address - Street 1:225 BROAD ST
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-4003
Practice Address - Country:US
Practice Address - Phone:843-479-0305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ29062Medicaid
SC2906OtherDELTA DENTAL PROVIDER #