Provider Demographics
NPI:1467464065
Name:BEETSTRA, STEPHEN M
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:BEETSTRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1581 DODD DR.
Mailing Address - Street 2:MCCAMPBELL HALL RM. 345
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1257
Mailing Address - Country:US
Mailing Address - Phone:614-685-3197
Mailing Address - Fax:614-685-3212
Practice Address - Street 1:1581 DODD DR.
Practice Address - Street 2:MCCAMPBELL HALL -RM. 345
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-4321
Practice Address - Country:US
Practice Address - Phone:614-685-3197
Practice Address - Fax:614-685-3212
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300260441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0411082Medicaid