Healthcare Provider Details

I. General information

NPI: 1568834117
Provider Name (Legal Business Name): MICHAEL A BECKERMAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 W BANKHEAD HWY
VILLA RICA GA
30180-1703
US

IV. Provider business mailing address

512 W BANKHEAD HWY
VILLA RICA GA
30180-1703
US

V. Phone/Fax

Practice location:
  • Phone: 770-459-5179
  • Fax: 770-459-5146
Mailing address:
  • Phone: 770-549-5197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN014339
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN014339
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: