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General NPI Number Information
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NPI Number | 1043374176
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Entity Type | Organization
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Legal Business Name | 12TH STREET DENTAL OFFICE PA
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Dates
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Enumeration Date | 12/21/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1008 12TH STREET SE
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City | ROCHESTER
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State | MN
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Zip | 55904-5030
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Country | US
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Telephone | 507-282-6448
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Fax | 507-287-8846
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Provider Business Mailing Address
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Address Line | 1008 12TH STREET SE
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City | ROCHESTER
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State | MN
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Zip | 55904-5030
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Country | US
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Telephone | 507-282-6448
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Fax | 507-287-8846
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Authorized Official
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Title or Position | OWNER PARTNER DENTIST
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Name | DR. JOSEPH GERARD BECKER
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Credential | DDS
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Telephone | 507-282-6448
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | MN9567
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License Number State | MN
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