Healthcare Provider Details

I. General information

NPI: 1902070865
Provider Name (Legal Business Name): BEACHCREST DENTAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 BEACH ST
WESTERLY RI
02891-2718
US

IV. Provider business mailing address

88 BEACH ST
WESTERLY RI
02891-2718
US

V. Phone/Fax

Practice location:
  • Phone: 401-596-0075
  • Fax: 401-596-0388
Mailing address:
  • Phone: 401-596-0075
  • Fax: 401-596-0388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. BRUCE CHARLES MACKINNON
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 401-596-0075