Bruce Farrell Becker, DDS
Individual provider Active NPI General Practice Dentistry · Plymouth, IN
NPI 1770745374 · NPPES record last updated Jun 26, 2008
Key facts
- NPI
- 1770745374
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Dentistry 1223G0001X
- License
- 12009200 (IN)
- Practice address
- 556 N Oak Road
Light House Dental
Plymouth, IN 46563-1664 - Phone
- (574) 936-3921
- Fax
- (574) 936-1010
- NPI assigned
- Jun 26, 2008
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IN
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160421001875 | IN | Order and Referring Only - Dentist |
9638478837 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 12009200 | IN | MD | General Practice Dentistry |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 12009200 | IN | Yes |
Addresses
Primary practice location
556 N Oak Road
Light House Dental
Plymouth, IN 46563-1664
Mailing address
556 N Oak Road
Light House Dental
Plymouth, IN 46563-1664
Phone (574) 936-3921
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 200151790B | Medicaid | IN |
Other providers in Plymouth, IN
- Stephen J Barber
- Scott Kelley Barger
- Carlos Bastardo
- Beacon Medical Group, Inc.
- Sally Beazlie-Walker
- Kelsey K Bell
- Teresa Benefit
- Berger Audiology
- Jeana Renee Berger
- Rebecca L Berger
All providers in Plymouth, IN · General Practice Dentistry in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 26, 2008. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.