Healthcare Provider Details

I. General information

NPI: 1427067289
Provider Name (Legal Business Name): JAY R BEAGLE DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 E 98TH ST STE 200
INDIANAPOLIS IN
46280-1973
US

IV. Provider business mailing address

3003 E 98TH ST STE 200
INDIANAPOLIS IN
46280-1973
US

V. Phone/Fax

Practice location:
  • Phone: 317-843-1281
  • Fax: 317-574-9390
Mailing address:
  • Phone: 317-843-1281
  • Fax: 317-574-9390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12008366A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: