Healthcare Provider Details

I. General information

NPI: 1396035416
Provider Name (Legal Business Name): BRIAN BECKSTROM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2011
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1091 N BLUFF ST STE 550
ST GEORGE UT
84770
US

IV. Provider business mailing address

1091 N BLUFF ST STE 550
ST GEORGE UT
84770-5775
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 TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberS3-248
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9366743-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: