Provider Demographics
NPI:1134752637
Name:BEATTIE, MAXWELL S (DDS)
Entity type:Individual
Prefix:DR
First Name:MAXWELL
Middle Name:S
Last Name:BEATTIE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 S ORLEANS AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1463
Mailing Address - Country:US
Mailing Address - Phone:419-308-1311
Mailing Address - Fax:
Practice Address - Street 1:4225 TALMADGE RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-3505
Practice Address - Country:US
Practice Address - Phone:419-241-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601097122300000X
OH30.026099122300000X, 1223E0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program