Healthcare Provider Details

I. General information

NPI: 1902535974
Provider Name (Legal Business Name): LORI K BECKER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 06/06/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 S LAKE DR APT 4
ST FRANCIS WI
53235-5256
US

IV. Provider business mailing address

200960 DUBAY DR
MOSINEE WI
54455-7504
US

V. Phone/Fax

Practice location:
  • Phone: 407-375-3003
  • Fax: 800-863-5373
Mailing address:
  • Phone: 715-355-7920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number6733-016
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: