Provider Demographics
NPI:1073716130
Name:BECKER, JOHN MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:BECKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 S FORT THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-2453
Mailing Address - Country:US
Mailing Address - Phone:859-781-4000
Mailing Address - Fax:859-781-4104
Practice Address - Street 1:1463 S FORT THOMAS AVE
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-2453
Practice Address - Country:US
Practice Address - Phone:859-781-4000
Practice Address - Fax:859-781-4104
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6030122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist