Provider Demographics
NPI:1174652317
Name:BECK, OTIS GLENN JR (DMD)
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:GLENN
Last Name:BECK
Suffix:JR
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 1:2929B CAPITAL MEDICAL BLVD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4407
Mailing Address - Country:US
Mailing Address - Phone:850-656-2636
Mailing Address - Fax:850-656-0220
Practice Address - Street 1:2929B CAPITAL MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4407
Practice Address - Country:US
Practice Address - Phone:850-656-2636
Practice Address - Fax:850-656-0220
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8116122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist