=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689798068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOPHIA DIANA BEASON-BROWN D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 381 HOPMEADOW ST, SUITE 301
-----------------------------------------------------
City | WEATOGUE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-232-9002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2595 ALBANY AVE
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06117-2302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-308-2433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 009594
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 009594
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------