MEDICARE: DR. WILLIE KEITH BEASLEY DDS

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	7175	VA

General Provider Information

NPI Number	:	1356346266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIE KEITH BEASLEY DDS

Provider Business Mailing Address
First Line	:	205 WEST ST NW
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22180-4416
Country	:	US
Telephone Number	:	703-255-0054
Fax Number	:	703-255-0779

Provider Business Practice Location Address
First Line	:	6211 CENTREVILLE RD
Second Line	:	STE 600
City	:	CENTREVILLE
State	:	VA
Zip	:	20121-2635
Country	:	US
Telephone Number	:	703-961-8808
Fax Number	:

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

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	07/08/2007

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