MEDICARE: DR. CHARLES RUNNELS BEAVERS D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4453	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4453	OTHER	OK	STATE DENTAL LICENSE

General Provider Information

NPI Number	:	1083654644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES RUNNELS BEAVERS D.D.S.

Provider Business Mailing Address
First Line	:	6050 S MAY AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-1402
Country	:	US
Telephone Number	:	405-682-9557
Fax Number	:

Provider Business Practice Location Address
First Line	:	6050 S MAY AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-1402
Country	:	US
Telephone Number	:	405-682-9557
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. CHARLES RUNNELS BEAVERS D.D.S.” Practice Location

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