Healthcare Provider Details

I. General information

NPI: 1245254432
Provider Name (Legal Business Name): BARRY ROBERT BEAUCHAMP D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 W SAINT CLAIR ST
MARINE CITY MI
48039-3544
US

IV. Provider business mailing address

2162 HUNTERS PARK E
SAINT CLAIR MI
48079-4013
US

V. Phone/Fax

Practice location:
  • Phone: 810-765-9200
  • Fax: 810-765-6460
Mailing address:
  • Phone: 810-329-5211
  • Fax: 810-765-6460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901015117
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: