Provider Demographics
NPI:1740560739
Name:BEACH DENTAL GROUP INC
Entity Type:Organization
Organization Name:BEACH DENTAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:A
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:DENTIS
Authorized Official - Phone:386-428-6491
Mailing Address - Street 1:809 STATE ROAD 44
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7271
Mailing Address - Country:US
Mailing Address - Phone:386-428-6491
Mailing Address - Fax:
Practice Address - Street 1:34 DORMER DR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-1051
Practice Address - Country:US
Practice Address - Phone:386-428-6491
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15016122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty