Provider Demographics
NPI:1154527018
Name:BEVERLY, KATINA RENE (DDS)
Entity type:Individual
Prefix:DR
First Name:KATINA
Middle Name:RENE
Last Name:BEVERLY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5317
Mailing Address - Country:US
Mailing Address - Phone:318-805-9000
Mailing Address - Fax:318-805-0345
Practice Address - Street 1:1203 N 5TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5317
Practice Address - Country:US
Practice Address - Phone:318-805-9000
Practice Address - Fax:318-805-0345
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA58561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry