1285740878 NPI number — BRADLEY D BECKER DDS PA

Table of content: (NPI 1285740878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285740878 NPI number — BRADLEY D BECKER DDS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRADLEY D BECKER DDS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RIVER VALLEY SMILE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285740878
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 OLD GREENWOOD RD
Provider Second Line Business Mailing Address:
STE 2
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72903-5929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-646-0706
Provider Business Mailing Address Fax Number:
479-646-0502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3600 OLD GREENWOOD RD
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72903-5929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-646-0706
Provider Business Practice Location Address Fax Number:
479-646-0502
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BECKER
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
479-646-0706

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3503 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5Y750 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 1821165 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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