Provider Demographics
NPI:1376769455
Name:BEAUCHESNE, LYNNEL CONSTANCE DICKSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:LYNNEL
Middle Name:CONSTANCE DICKSON
Last Name:BEAUCHESNE
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:RR 2 BOX 181-23
Mailing Address - Street 2:
Mailing Address - City:TUNNELTON
Mailing Address - State:WV
Mailing Address - Zip Code:26444-9642
Mailing Address - Country:US
Mailing Address - Phone:304-892-4653
Mailing Address - Fax:304-892-3943
Practice Address - Street 1:RR 2 BOX 181-23
Practice Address - Street 2:
Practice Address - City:TUNNELTON
Practice Address - State:WV
Practice Address - Zip Code:26444-9642
Practice Address - Country:US
Practice Address - Phone:304-892-4653
Practice Address - Fax:304-892-3943
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV33171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0134475000Medicaid
WV3317OtherLICENSE