Provider Demographics
NPI:1922166578
Name:BEAUDRY, DOUGLAS L (DDS, PS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:L
Last Name:BEAUDRY
Suffix:
Gender:M
Credentials:DDS, PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 12TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:WA
Mailing Address - Zip Code:98823-2197
Mailing Address - Country:US
Mailing Address - Phone:509-754-3262
Mailing Address - Fax:509-754-3262
Practice Address - Street 1:204 12TH AVE SW
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:WA
Practice Address - Zip Code:98823-2197
Practice Address - Country:US
Practice Address - Phone:509-754-3262
Practice Address - Fax:509-754-3262
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000045981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4598OtherSTATE DENTAL LICENSE #
WA5543103Medicaid
WA05431OtherWDS LICENSE #
WA4598OtherSTATE DENTAL LICENSE #