Provider Demographics
NPI:1235410028
Name:BEASLEY, STACIE D (DDS)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:D
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2965 S MACARTHUR BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-5087
Mailing Address - Country:US
Mailing Address - Phone:217-698-1717
Mailing Address - Fax:217-698-7134
Practice Address - Street 1:2965 S MACARTHUR BLVD STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-5087
Practice Address - Country:US
Practice Address - Phone:217-698-1717
Practice Address - Fax:217-698-7134
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028850122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist