Provider Demographics
NPI:1104189893
Name:BECK, JONATHAN AVERY (DDS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:AVERY
Last Name:BECK
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 1:530 DEMOSS STREET
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2618
Mailing Address - Country:US
Mailing Address - Phone:575-542-8384
Mailing Address - Fax:
Practice Address - Street 1:114 W 11TH STREET
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-5136
Practice Address - Country:US
Practice Address - Phone:575-388-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3675122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist