Provider Demographics
NPI:1821253931
Name:BECKER BORIS P DDS PC
Entity Type:Organization
Organization Name:BECKER BORIS P DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-622-0400
Mailing Address - Street 1:214 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-2274
Mailing Address - Country:US
Mailing Address - Phone:847-622-0400
Mailing Address - Fax:847-622-7818
Practice Address - Street 1:214 RANDALL RD
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-2274
Practice Address - Country:US
Practice Address - Phone:847-622-0400
Practice Address - Fax:847-622-7818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190252131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1004729Medicaid