Healthcare Provider Details

I. General information

NPI: 1932100609
Provider Name (Legal Business Name): RALPH ROBERT BETON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 MONTREAL RD SU 204
TUCKER GA
30084-6900
US

IV. Provider business mailing address

1459 MONTREAL RD SU 204
TUCKER GA
30084-6926
US

V. Phone/Fax

Practice location:
  • Phone: 770-939-4721
  • Fax: 770-939-1187
Mailing address:
  • Phone: 770-939-4721
  • Fax: 770-939-1187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number31207
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: