Provider Demographics
NPI:1790849404
Name:BEAVERS, NATHAN KEIL (DMD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:KEIL
Last Name:BEAVERS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:119 COLONY CROSSING WAY
Mailing Address - Street 2:SUITE 740
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6322
Mailing Address - Country:US
Mailing Address - Phone:601-856-5313
Mailing Address - Fax:601-856-5552
Practice Address - Street 1:312 FOUNTAINS DRIVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:601-856-5313
Practice Address - Fax:601-856-5552
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPEDO 377-041223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08101262Medicaid