Healthcare Provider Details

I. General information

NPI: 1750466678
Provider Name (Legal Business Name): JAN BRUCE BECKSTRAND D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 SOUTH MAIN STREET
FILLMORE UT
84631
US

IV. Provider business mailing address

PO BOX 808
FILLMORE UT
84631-0808
US

V. Phone/Fax

Practice location:
  • Phone: 435-743-6521
  • Fax: 435-743-6521
Mailing address:
  • Phone: 435-743-6521
  • Fax: 435-743-6521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2223
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: