Healthcare Provider Details

I. General information

NPI: 1720284698
Provider Name (Legal Business Name): REX BEASOM PAINTER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 DOLPHIN DR
ST AUGUSTINE FL
32080-4531
US

IV. Provider business mailing address

10 DOLPHIN DR
ST AUGUSTINE FL
32080-4531
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-8652
  • Fax: 904-824-9169
Mailing address:
  • Phone: 904-824-8652
  • Fax: 904-824-9169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN0013507
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: