Provider Demographics
NPI:1679932685
Name:KEN A BECKERMAN DDS LLC
Entity type:Organization
Organization Name:KEN A BECKERMAN DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BECKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-385-2750
Mailing Address - Street 1:304 LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:IN
Mailing Address - Zip Code:47640-8820
Mailing Address - Country:US
Mailing Address - Phone:812-385-2750
Mailing Address - Fax:
Practice Address - Street 1:109 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IN
Practice Address - Zip Code:47670-1501
Practice Address - Country:US
Practice Address - Phone:812-385-2750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty