Provider Demographics
NPI:1770628224
Name:DEACON, BEVERLY DENISE (DDS)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:DENISE
Last Name:DEACON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 DUKE OF GLOUCESTER ST STE 112
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2073
Mailing Address - Country:US
Mailing Address - Phone:972-296-9760
Mailing Address - Fax:
Practice Address - Street 1:2828 DUKE OF GLOUCESTER ST STE 112
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2073
Practice Address - Country:US
Practice Address - Phone:972-296-9760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX156111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice