=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952962458
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL BECKERMAN DMD & ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2019
-----------------------------------------------------
Last Update Date | 06/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 512 W BANKHEAD HWY
-----------------------------------------------------
City | VILLA RICA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30180-1703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-459-5197
-----------------------------------------------------
Fax | 770-459-5146
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 512 W BANKHEAD HWY
-----------------------------------------------------
City | VILLA RICA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30180-1703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-459-5197
-----------------------------------------------------
Fax | 770-459-5146
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL A BECKERMAN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 678-523-9007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------