Provider Demographics
NPI:1740367804
Name:BEATTY, MARK WILLIAM (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
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 1:2000 S 26TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68502-3025
Mailing Address - Country:US
Mailing Address - Phone:402-472-1261
Mailing Address - Fax:
Practice Address - Street 1:4101 WOOLWORTH
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105
Practice Address - Country:US
Practice Address - Phone:402-472-1261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE5791122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist