Provider Demographics
NPI:1043871445
Name:BEARD, AVERY BROOKE (DMD)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:BROOKE
Last Name:BEARD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13121 E 21ST ST N STE 107
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67230-7403
Mailing Address - Country:US
Mailing Address - Phone:316-630-9500
Mailing Address - Fax:
Practice Address - Street 1:13121 E 21ST ST N STE 107
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67230-7403
Practice Address - Country:US
Practice Address - Phone:316-630-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS62661122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS62661OtherDENTAL LICENSE