Provider Demographics
NPI:1194934059
Name:BEATTY, LUCAS ROBERT (DDS, MD)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:ROBERT
Last Name:BEATTY
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15515 3RD AVE SW
Mailing Address - Street 2:SUITE E
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-2553
Mailing Address - Country:US
Mailing Address - Phone:206-248-3035
Mailing Address - Fax:
Practice Address - Street 1:15515 3RD AVE SW
Practice Address - Street 2:SUITE E
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-2553
Practice Address - Country:US
Practice Address - Phone:206-248-3035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD72551223S0112X
WADE601725921223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery