=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730880675
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BECKLEY FAMILY DENTAL GROUP, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2023
-----------------------------------------------------
Last Update Date | 03/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 146 SW 2ND AVE
-----------------------------------------------------
City | CANBY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97013-4152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-266-5596
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23 FALSTAFF ST
-----------------------------------------------------
City | LAKE OSWEGO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97035-1901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-784-8305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDTN/SECRETARY
-----------------------------------------------------
Name | DR. STEFANIE M BECKLEY
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 541-784-8305
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------