Healthcare Provider Details

I. General information

NPI: 1891825543
Provider Name (Legal Business Name): ANGELA RENEE BECKER DDS MSD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA PYLE

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4638 W JEFFERSON BLVD
FORT WAYNE IN
46804-6886
US

IV. Provider business mailing address

4638 W JEFFERSON BLVD
FORT WAYNE IN
46804-6886
US

V. Phone/Fax

Practice location:
  • Phone: 260-432-2147
  • Fax: 260-432-4968
Mailing address:
  • Phone: 260-432-2147
  • Fax: 260-432-4968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12009655A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: