Provider Demographics
NPI:1770745374
Name:BECKER, BRUCE FARRELL (DDS)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:FARRELL
Last Name:BECKER
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 1:556 N OAK ROAD
Mailing Address - Street 2:LIGHT HOUSE DENTAL
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-1664
Mailing Address - Country:US
Mailing Address - Phone:574-936-3921
Mailing Address - Fax:574-936-1010
Practice Address - Street 1:556 N OAK ROAD
Practice Address - Street 2:LIGHT HOUSE DENTAL
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1664
Practice Address - Country:US
Practice Address - Phone:574-936-3921
Practice Address - Fax:574-936-1010
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120092001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200151790BMedicaid