=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619321734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACQUELINE M. BEARD, DMD, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2016
-----------------------------------------------------
Last Update Date | 04/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34501 AURORA RD SUITE 305
-----------------------------------------------------
City | SOLON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44139-3873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-528-1399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35401 AURORA ROAD SUITE 305
-----------------------------------------------------
City | SOLON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44139-3808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-528-1399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRIC DENTIST/PRESIDENT
-----------------------------------------------------
Name | DR. JACQUELINE M. BEARD
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 440-223-8767
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 30.023827
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------