Provider Demographics
NPI:1528182987
Name:BEASELY, STEVE MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:STEVE
Middle Name:MICHAEL
Last Name:BEASELY
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 1:4008 MAPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-6354
Mailing Address - Country:US
Mailing Address - Phone:337-625-5697
Mailing Address - Fax:337-626-1329
Practice Address - Street 1:4008 MAPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-6354
Practice Address - Country:US
Practice Address - Phone:337-625-5697
Practice Address - Fax:337-626-1329
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4045122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1840459Medicaid