Provider Demographics
NPI:1740649839
Name:BECERRA, JUSTIN FORD (DDS)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:FORD
Last Name:BECERRA
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 1:11332 CENTRAL CT
Mailing Address - Street 2:APT 15209
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-5045
Mailing Address - Country:US
Mailing Address - Phone:808-979-4771
Mailing Address - Fax:
Practice Address - Street 1:2323 S WADSWORTH BLVD STE 1778
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80227-3274
Practice Address - Country:US
Practice Address - Phone:303-980-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002028511223G0001X
390200000X
CODEN.002028511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO003540281OtherDRIVERS LICENSE