Healthcare Provider Details

I. General information

NPI: 1932208014
Provider Name (Legal Business Name): BRUCE MYRON BECKHAM D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 GREEN ST NW
GAINESVILLE GA
30501-3378
US

IV. Provider business mailing address

615 GREEN ST NW
GAINESVILLE GA
30501-3378
US

V. Phone/Fax

Practice location:
  • Phone: 770-535-0509
  • Fax: 770-535-0973
Mailing address:
  • Phone: 770-535-0509
  • Fax: 770-535-0973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number9999
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: