Healthcare Provider Details

I. General information

NPI: 1124080973
Provider Name (Legal Business Name): LEAH G BEAVERS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 05/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 W CHATHAM ST
APEX NC
27502-1415
US

IV. Provider business mailing address

619 W CHATHAM ST
APEX NC
27502-1415
US

V. Phone/Fax

Practice location:
  • Phone: 919-362-0967
  • Fax: 919-355-1551
Mailing address:
  • Phone: 919-362-0967
  • Fax: 919-355-1551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5601
License Number StateLA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1651885
Identifier TypeOTHER
Identifier State
Identifier IssuerUNITED CONCORDIA
# 2
Identifier1856011
Identifier TypeMEDICAID
Identifier StateLA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: