Provider Demographics
NPI:1841652559
Name:BEAULIEU, MICHAEL ANDREW (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANDREW
Last Name:BEAULIEU
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 1:6410 FANNIN ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-3000
Mailing Address - Country:US
Mailing Address - Phone:713-500-5888
Mailing Address - Fax:
Practice Address - Street 1:6410 FANNIN ST
Practice Address - Street 2:SUITE 310
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3000
Practice Address - Country:US
Practice Address - Phone:713-500-5888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31682122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist