Healthcare Provider Details

I. General information

NPI: 1639745326
Provider Name (Legal Business Name): STEPHANIE BECKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5004 CAROLINA FOREST BLVD.
MYRTLE BEACH SC
29579
US

IV. Provider business mailing address

5004 CAROLINA FOREST BLVD.
MYRTLE BEACH SC
29579
US

V. Phone/Fax

Practice location:
  • Phone: 843-380-9080
  • Fax:
Mailing address:
  • Phone: 843-380-9080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9862
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: