Healthcare Provider Details

I. General information

NPI: 1174057319
Provider Name (Legal Business Name): BRIAN L. BECKSTROM P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2017
Last Update Date: 04/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1091 N BLUFF ST SUITE 550
ST GEORGE UT
84770-4894
US

IV. Provider business mailing address

1091 N BLUFF ST SUITE 550
ST GEORGE UT
84770-4894
US

V. Phone/Fax

Practice location:
  • Phone: 435-628-6200
  • Fax: 435-652-9051
Mailing address:
  • Phone: 435-628-6200
  • Fax: 435-652-9051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number93667439921
License Number StateUT

VIII. Authorized Official

Name: DR. BRIAN BECKSTROM
Title or Position: PRESIDENT/ORTHODONTIST
Credential: DDS, MSD
Phone: 435-628-6200