Provider Demographics
NPI:1013395136
Name:BECKER, MEGAN (MDT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:BECKER
Suffix:
Gender:F
Credentials:MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8196 SHADYVIEW LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-1700
Mailing Address - Country:US
Mailing Address - Phone:763-913-9441
Mailing Address - Fax:
Practice Address - Street 1:12936 63RD AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-6001
Practice Address - Country:US
Practice Address - Phone:763-559-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT58125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist