Provider Demographics
NPI:1447703426
Name:BEASLEY, NICOLE ELIZABETH (DMD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HEALTH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910-8161
Mailing Address - Country:US
Mailing Address - Phone:252-332-1904
Mailing Address - Fax:
Practice Address - Street 1:100 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-8161
Practice Address - Country:US
Practice Address - Phone:252-332-1904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1447703426Medicaid
NC1447703426OtherDELTA DENTAL OF NC