Healthcare Provider Details

I. General information

NPI: 1053761668
Provider Name (Legal Business Name): CHARLES G BEALS D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 05/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11400 158TH RD
MAYETTA KS
66509
US

IV. Provider business mailing address

11400 158TH RD
MAYETTA KS
66509-8866
US

V. Phone/Fax

Practice location:
  • Phone: 785-966-8290
  • Fax:
Mailing address:
  • Phone: 785-966-8290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number61195
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: