Provider Demographics
NPI:1538509500
Name:BECKER, MITCHELL ELI (DMD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:ELI
Last Name:BECKER
Suffix:
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 1:4323 HILL STREET
Mailing Address - Street 2:USA DENTAL ACTIVITY
Mailing Address - City:FORT JACKSON
Mailing Address - State:SC
Mailing Address - Zip Code:29207-6022
Mailing Address - Country:US
Mailing Address - Phone:803-751-6213
Mailing Address - Fax:803-751-6886
Practice Address - Street 1:4323 HILL STREET
Practice Address - Street 2:USA DENTAL ACTIVITY
Practice Address - City:FORT JACKSON
Practice Address - State:SC
Practice Address - Zip Code:29207-6022
Practice Address - Country:US
Practice Address - Phone:803-751-6213
Practice Address - Fax:803-751-6886
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-05
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0396071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice