Provider Demographics
NPI:1356440135
Name:BEARDEN, KATIE SEVELDA (DDS)
Entity type:Individual
Prefix:DR
First Name:KATIE
Middle Name:SEVELDA
Last Name:BEARDEN
Suffix:
Gender:F
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:PO BOX 1583
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-4083
Mailing Address - Country:US
Mailing Address - Phone:662-563-5040
Mailing Address - Fax:662-563-5018
Practice Address - Street 1:221 GAY ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-1903
Practice Address - Country:US
Practice Address - Phone:662-563-5040
Practice Address - Fax:662-563-5018
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2655-911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060448Medicaid