=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194934059
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUCAS ROBERT BEATTY D.D.S., M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 12/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15515 3RD AVE SW SUITE E
-----------------------------------------------------
City | BURIEN
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98166-2553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-248-3035
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15515 3RD AVE SW SUITE E
-----------------------------------------------------
City | BURIEN
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98166-2553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-248-3035
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | D7255
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DE60172592
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------