Basic Information
| Provider Information | |||||||||
| NPI: | 1518198019 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEAUCHAMP | ||||||||
| FirstName: | TED | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | BLDG 2441 21ST STREET | ||||||||
| Address2: | ATTN MRS. MORGAN (CREDENTIALS) CDR, U S ARMY DENTAL ACT | ||||||||
| City: | FT. CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235369 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2441 21ST STREET | ||||||||
| Address2: | US ARMY DENTAL ACTIVITY | ||||||||
| City: | FT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988977 | ||||||||
| FaxNumber: | 2709560266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2009 | ||||||||
| LastUpdateDate: | 06/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2009013186 | MO | N | Dental Providers | Dentist | 1223E0200X | 2009013186 | MO | Y | Dental Providers | Dentist | Endodontics |
No ID Information.