Provider Demographics
NPI:1194928622
Name:BEAM, MARY JAY (DMD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:JAY
Last Name:BEAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MARY JAY
Other - Middle Name:BEAM
Other - Last Name:KIK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:12907 FACTORY LN STE B
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5433
Mailing Address - Country:US
Mailing Address - Phone:502-206-2460
Mailing Address - Fax:
Practice Address - Street 1:12907 FACTORY LN STE B
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-5433
Practice Address - Country:US
Practice Address - Phone:502-206-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120110421223G0001X
KY84961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice