Provider Demographics
NPI:1093832875
Name:BECKETT, RUSSELL P (DDS)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:P
Last Name:BECKETT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:47362-4355
Mailing Address - Country:US
Mailing Address - Phone:765-521-0390
Mailing Address - Fax:765-529-3218
Practice Address - Street 1:1520 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:IN
Practice Address - Zip Code:47362-4355
Practice Address - Country:US
Practice Address - Phone:765-521-0390
Practice Address - Fax:765-529-3218
Is Sole Proprietor?:No
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120071341223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN352690Medicare ID - Type Unspecified