Provider Demographics
NPI:1750763074
Name:BECKER, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:BECKER
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 1:1046 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80203-5242
Mailing Address - Country:US
Mailing Address - Phone:720-767-2851
Mailing Address - Fax:
Practice Address - Street 1:1046 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80203-5242
Practice Address - Country:US
Practice Address - Phone:720-767-2851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8663122300000X
IN12012308A122300000X
CO00203148122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COZX8663Medicaid