Healthcare Provider Details

I. General information

NPI: 1992822811
Provider Name (Legal Business Name): ROGER DUANE BECK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2007
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3470 E MERIDIAN PARK LOOP
WASILLA AK
99654-7294
US

IV. Provider business mailing address

3470 E MERIDIAN PARK LOOP
WASILLA AK
99654-7294
US

V. Phone/Fax

Practice location:
  • Phone: 907-373-8684
  • Fax: 907-373-8465
Mailing address:
  • Phone: 907-373-8684
  • Fax: 907-373-8465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number924
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number101
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1003811
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: