Provider Demographics
NPI:1437299989
Name:BECKERMAN, KEN A (DDS)
Entity Type:Individual
Prefix:MR
First Name:KEN
Middle Name:A
Last Name:BECKERMAN
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 1:109 W BROADWAY ST
Mailing Address - Street 2:PO BOX 462
Mailing Address - City:PRINCETON
Mailing Address - State:IN
Mailing Address - Zip Code:47670-1501
Mailing Address - Country:US
Mailing Address - Phone:812-385-2750
Mailing Address - Fax:812-385-2878
Practice Address - Street 1:109 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IN
Practice Address - Zip Code:47670-1501
Practice Address - Country:US
Practice Address - Phone:812-385-2750
Practice Address - Fax:812-385-2878
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120078381223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1437299989OtherINDIVIDUAL NPI
IN1437299989OtherINDIVIDUAL NPI
7540000001Medicare PIN