Provider Demographics
NPI:1407928682
Name:SMALL, BETHANY SUE
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:SUE
Last Name:SMALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 AVON BELDEN RD
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-2295
Mailing Address - Country:US
Mailing Address - Phone:440-930-5233
Mailing Address - Fax:440-930-5234
Practice Address - Street 1:424 AVON BELDEN RD
Practice Address - Street 2:
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-2295
Practice Address - Country:US
Practice Address - Phone:440-930-5233
Practice Address - Fax:440-930-5234
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice