Provider Demographics
NPI:1396035416
Name:BECKSTROM, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BECKSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1091 N BLUFF ST STE 550
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5775
Mailing Address - Country:US
Mailing Address - Phone:435-628-6200
Mailing Address - Fax:435-652-9051
Practice Address - Street 1:1091 N BLUFF ST STE 550
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:435-628-6200
Practice Address - Fax:435-652-9051
Is Sole Proprietor?:No
Enumeration Date:2011-04-10
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS3-2481223X0400X
UT9366743-99211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics