MEDICARE: DR. RANDY CARL BEARD D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	10180	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	35768 BE	OTHER	MN	BLUE CROSS BLUE SHIELD ID

General Provider Information

NPI Number	:	1447349535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDY CARL BEARD D.D.S.

Provider Business Mailing Address
First Line	:	113 MAIN ST S
Second Line	:	PO BOX 314
City	:	CLEARBROOK
State	:	MN
Zip	:	56634-0314
Country	:	US
Telephone Number	:	218-776-3558
Fax Number	:	218-776-2112

Provider Business Practice Location Address
First Line	:	113 MAIN ST S
Second Line	:
City	:	CLEARBROOK
State	:	MN
Zip	:	56634-0314
Country	:	US
Telephone Number	:	218-776-3558
Fax Number	:	218-776-2112

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/08/2007

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