Provider Demographics
NPI:1083654644
Name:BEAVERS, CHARLES RUNNELS (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RUNNELS
Last Name:BEAVERS
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 1:6050 S MAY AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-1402
Mailing Address - Country:US
Mailing Address - Phone:405-682-9557
Mailing Address - Fax:
Practice Address - Street 1:6050 S MAY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-1402
Practice Address - Country:US
Practice Address - Phone:405-682-9557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK44531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK4453OtherSTATE DENTAL LICENSE