Provider Demographics
NPI:1023192556
Name:BEAUCHAMP, DAVID N (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:N
Last Name:BEAUCHAMP
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 1:709 E SHOTWELL ST
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-4063
Mailing Address - Country:US
Mailing Address - Phone:229-246-3686
Mailing Address - Fax:229-246-5011
Practice Address - Street 1:709 E SHOTWELL ST
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4063
Practice Address - Country:US
Practice Address - Phone:229-246-3686
Practice Address - Fax:229-246-5011
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA92221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00205928AMedicaid