Provider Demographics
NPI:1295073377
Name:BEATTIE, SHELBY JACE (DDS)
Entity type:Individual
Prefix:DR
First Name:SHELBY
Middle Name:JACE
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 1:228 E LAURIDSEN BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-7821
Mailing Address - Country:US
Mailing Address - Phone:360-457-4850
Mailing Address - Fax:
Practice Address - Street 1:228 E LAURIDSEN BLVD
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-7821
Practice Address - Country:US
Practice Address - Phone:360-457-4850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE603303181223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics