Provider Demographics
NPI:1417053646
Name:BETHEA, DONALD ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:ALAN
Last Name:BETHEA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 LISTER ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-5226
Mailing Address - Country:US
Mailing Address - Phone:912-285-1218
Mailing Address - Fax:912-285-9518
Practice Address - Street 1:410 LISTER ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5226
Practice Address - Country:US
Practice Address - Phone:912-285-1218
Practice Address - Fax:912-285-9518
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0112251223P0221X
TNDS69721223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003143408AMedicaid