1770745374 NPI number — DR. BRUCE FARRELL BECKER DDS

Table of content: DR. BRUCE FARRELL BECKER DDS (NPI 1770745374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770745374 NPI number — DR. BRUCE FARRELL BECKER DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BECKER
Provider First Name:
BRUCE
Provider Middle Name:
FARRELL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770745374
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
556 N OAK ROAD
Provider Second Line Business Mailing Address:
LIGHT HOUSE DENTAL
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46563-1664
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-936-3921
Provider Business Mailing Address Fax Number:
574-936-1010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
556 N OAK ROAD
Provider Second Line Business Practice Location Address:
LIGHT HOUSE DENTAL
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46563-1664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-936-3921
Provider Business Practice Location Address Fax Number:
574-936-1010
Provider Enumeration Date:
06/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  12009200 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200151790B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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