Provider Demographics
NPI:1437186079
Name:BEASLEY, JUSTIN LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:LEE
Last Name:BEASLEY
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 1:10717 N ROCKWELL AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-4537
Mailing Address - Country:US
Mailing Address - Phone:405-721-2676
Mailing Address - Fax:405-722-8428
Practice Address - Street 1:10717 N ROCKWELL AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-4537
Practice Address - Country:US
Practice Address - Phone:405-721-2676
Practice Address - Fax:405-722-8428
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5661122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist