Healthcare Provider Details

I. General information

NPI: 1497747166
Provider Name (Legal Business Name): OLLIE LOGAN BEARD III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W LILLIE BLVD
MADILL OK
73446-1253
US

IV. Provider business mailing address

PO BOX 128 301 WEST LILLIE BLVD
MADILL OK
73446-0128
US

V. Phone/Fax

Practice location:
  • Phone: 580-795-5400
  • Fax: 580-795-5723
Mailing address:
  • Phone: 580-920-2292
  • Fax: 580-795-5273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3453
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: