Provider Demographics
NPI:1528179033
Name:BEALL DENTAL CENTER
Entity Type:Organization
Organization Name:BEALL DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AVERY
Authorized Official - Middle Name:PATTON
Authorized Official - Last Name:BEALL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:706-882-2597
Mailing Address - Street 1:106 CORPORATE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-2883
Mailing Address - Country:US
Mailing Address - Phone:706-882-2597
Mailing Address - Fax:
Practice Address - Street 1:106 CORPORATE PLAZA DR
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-2883
Practice Address - Country:US
Practice Address - Phone:706-882-2597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN008351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID NUMBER