Provider Demographics
NPI:1376693937
Name:DUDLEY C. BEATY III, DMD, PC
Entity Type:Organization
Organization Name:DUDLEY C. BEATY III, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUDLEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BEATY
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-479-0305
Mailing Address - Street 1:225 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-4003
Mailing Address - Country:US
Mailing Address - Phone:843-479-0305
Mailing Address - Fax:
Practice Address - Street 1:225 BROAD ST
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-4003
Practice Address - Country:US
Practice Address - Phone:843-479-0305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2906OtherDELTA DENTAL PROVIDER #
SCZA9903Medicaid
SC=========OtherBLUECROSS PROVIDER #