Provider Demographics
NPI:1790872307
Name:BEALL, FRED E SR (DDS PC)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:E
Last Name:BEALL
Suffix:SR
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2971 VINEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204
Mailing Address - Country:US
Mailing Address - Phone:478-746-0727
Mailing Address - Fax:478-746-0727
Practice Address - Street 1:2971 VINEVILLE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204
Practice Address - Country:US
Practice Address - Phone:478-746-0727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA6610122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist