Provider Demographics
NPI:1164543823
Name:BECKER, PAUL CLINTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:CLINTON
Last Name:BECKER
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 1:2725 WHITE OAK CIR
Mailing Address - Street 2:
Mailing Address - City:LONG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55356-9747
Mailing Address - Country:US
Mailing Address - Phone:952-473-2391
Mailing Address - Fax:
Practice Address - Street 1:1121 TOWN CENTRE DR STE 200
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1217
Practice Address - Country:US
Practice Address - Phone:651-454-4771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN97881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice