Provider Demographics
NPI:1457745002
Name:BEAUMONT DENTAL GROUP
Entity Type:Organization
Organization Name:BEAUMONT DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANU
Authorized Official - Middle Name:
Authorized Official - Last Name:DUCKWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-528-8556
Mailing Address - Street 1:930 BEAUMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-1831
Mailing Address - Country:US
Mailing Address - Phone:951-845-2200
Mailing Address - Fax:
Practice Address - Street 1:930 BEAUMONT AVE
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-1831
Practice Address - Country:US
Practice Address - Phone:951-845-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-22
Last Update Date:2015-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA643301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty