Provider Demographics
NPI:1932208014
Name:BECKHAM, BRUCE MYRON (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:MYRON
Last Name:BECKHAM
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 1:615 GREEN ST NW
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3378
Mailing Address - Country:US
Mailing Address - Phone:770-535-0509
Mailing Address - Fax:770-535-0973
Practice Address - Street 1:615 GREEN ST NW
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3378
Practice Address - Country:US
Practice Address - Phone:770-535-0509
Practice Address - Fax:770-535-0973
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA99991223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics