Healthcare Provider Details

I. General information

NPI: 1417979972
Provider Name (Legal Business Name): EDWARD J BECKER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15600 WASHINGTON AVE STE. A
SAN LORENZO CA
94580-1467
US

IV. Provider business mailing address

15600 WASHINGTON AVE STE. A
SAN LORENZO CA
94580-1467
US

V. Phone/Fax

Practice location:
  • Phone: 510-276-7124
  • Fax: 510-276-2132
Mailing address:
  • Phone: 510-276-7124
  • Fax: 510-276-2132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14549
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: