Healthcare Provider Details

I. General information

NPI: 1043193345
Provider Name (Legal Business Name): TINA BEETHAM HYGIENIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2025
Last Update Date: 07/26/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 22ND AVE
MONROE WI
53566-1576
US

IV. Provider business mailing address

685 COUNTY ROAD MM
OREGON WI
53575
US

V. Phone/Fax

Practice location:
  • Phone: 608-328-9404
  • Fax:
Mailing address:
  • Phone: 608-575-5046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2543-16
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: