Provider Demographics
NPI:1336368885
Name:BEATTY, JOHN M (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:BEATTY
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 1:2717 N CENTER ST
Mailing Address - Street 2:P.O. BOX 310
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5623
Mailing Address - Country:US
Mailing Address - Phone:618-288-0088
Mailing Address - Fax:618-288-3691
Practice Address - Street 1:2717 N CENTER ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5623
Practice Address - Country:US
Practice Address - Phone:618-288-0088
Practice Address - Fax:618-288-3691
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA126621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA12662OtherDENTAL LICENSE