Healthcare Provider Details

I. General information

NPI: 1235191917
Provider Name (Legal Business Name): ROBERT CHARLES BEAVER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 S SENECA SUITE A
WICHITA KS
67217
US

IV. Provider business mailing address

2860 S SENECA SUITE A
WICHITA KS
67217
US

V. Phone/Fax

Practice location:
  • Phone: 316-522-4719
  • Fax: 316-522-3398
Mailing address:
  • Phone: 316-522-4719
  • Fax: 316-522-3398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4306
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: