Provider Demographics
NPI:1780755959
Name:BEATY, GREGG W (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGG
Middle Name:W
Last Name:BEATY
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 1:3737 MORAGA AVE
Mailing Address - Street 2:SUITE B-200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5404
Mailing Address - Country:US
Mailing Address - Phone:858-272-7086
Mailing Address - Fax:858-272-7289
Practice Address - Street 1:3737 MORAGA AVE
Practice Address - Street 2:SUITE B-200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-5404
Practice Address - Country:US
Practice Address - Phone:858-272-7086
Practice Address - Fax:858-272-7289
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0344671223S0112X
WI4036-0151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery