Provider Demographics
NPI:1194933028
Name:BEAVERS, EDWARD LEE (DDS)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:LEE
Last Name:BEAVERS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:EDWARD
Other - Middle Name:LEE
Other - Last Name:BEAVERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:603 NW ATLANTIC ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-3536
Mailing Address - Country:US
Mailing Address - Phone:931-455-3501
Mailing Address - Fax:
Practice Address - Street 1:603 NW ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-3536
Practice Address - Country:US
Practice Address - Phone:931-455-3501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice