Provider Demographics
NPI:1598968067
Name:WAYNE M. BEAVERS, D.D.S., P.A.
Entity Type:Organization
Organization Name:WAYNE M. BEAVERS, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.D.S.
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BEAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-467-2714
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:919-467-2714
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:919-467-2714
Practice Address - Fax:919-467-2520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990553Medicaid