Provider Demographics
NPI:1356410633
Name:BEAVER, PHILLIP DANIEL (DDS)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:DANIEL
Last Name:BEAVER
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 1:1209 DAVIE AVE
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-3511
Mailing Address - Country:US
Mailing Address - Phone:704-872-8934
Mailing Address - Fax:
Practice Address - Street 1:1209 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3511
Practice Address - Country:US
Practice Address - Phone:704-872-8934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8056122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist