Provider Demographics
NPI:1265621643
Name:BEACH DENTAL ASSOCIATES
Entity type:Organization
Organization Name:BEACH DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-692-9313
Mailing Address - Street 1:9654 N KINGS HWY
Mailing Address - Street 2:SUITE N
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4040
Mailing Address - Country:US
Mailing Address - Phone:843-692-9313
Mailing Address - Fax:843-692-2584
Practice Address - Street 1:9654 N KINGS HWY
Practice Address - Street 2:SUITE N
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4040
Practice Address - Country:US
Practice Address - Phone:843-692-9313
Practice Address - Fax:843-692-2584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9825Medicaid