Provider Demographics
NPI:1912928292
Name:BEATY, JOHN C (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
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 1:585 SOLITAIRE PALM DR
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-3852
Mailing Address - Country:US
Mailing Address - Phone:321-452-8334
Mailing Address - Fax:321-452-8335
Practice Address - Street 1:113 N BANANA RIVER DR
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-2546
Practice Address - Country:US
Practice Address - Phone:321-452-8334
Practice Address - Fax:321-452-8335
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00108791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice