Provider Demographics
NPI:1194198861
Name:BEATTIE, LEAH M (EPDH)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:M
Last Name:BEATTIE
Suffix:
Gender:F
Credentials:EPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 ST JOHN ST
Mailing Address - Street 2:PO BOX 1103
Mailing Address - City:SUTHERLIN
Mailing Address - State:OR
Mailing Address - Zip Code:97479-9643
Mailing Address - Country:US
Mailing Address - Phone:541-430-4160
Mailing Address - Fax:
Practice Address - Street 1:2700 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1281
Practice Address - Country:US
Practice Address - Phone:541-677-4851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH4025124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist