Provider Demographics
NPI:1023080710
Name:BECKER, MICHAEL DAMIAN (DMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAMIAN
Last Name:BECKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11518 SARATOGA CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-4374
Mailing Address - Country:US
Mailing Address - Phone:502-648-2495
Mailing Address - Fax:
Practice Address - Street 1:119 TOPFIELD RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40229-4462
Practice Address - Country:US
Practice Address - Phone:502-957-4408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411263122300000X
KY8569122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist