Provider Demographics
NPI:1366679953
Name:BEASLEY, ROBERT T (DMD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 28TH ST NE STE 1
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-2560
Mailing Address - Country:US
Mailing Address - Phone:507-242-1441
Mailing Address - Fax:507-242-1445
Practice Address - Street 1:125 28TH ST NE STE 1
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-2560
Practice Address - Country:US
Practice Address - Phone:507-242-1441
Practice Address - Fax:507-242-1445
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND130491223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics