Provider Demographics
NPI:1598190639
Name:BEAVERS, KEITH EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:EDWARD
Last Name:BEAVERS
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 1:1146 EXECUTIVE CIR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-4526
Mailing Address - Country:US
Mailing Address - Phone:919-467-0654
Mailing Address - Fax:919-467-2520
Practice Address - Street 1:1146 EXECUTIVE CIR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-4526
Practice Address - Country:US
Practice Address - Phone:919-467-0654
Practice Address - Fax:919-467-2520
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9595122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist