Provider Demographics
NPI:1174057319
Name:BRIAN L. BECKSTROM P.C.
Entity type:Organization
Organization Name:BRIAN L. BECKSTROM P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:435-628-6200
Mailing Address - Street 1:1091 N BLUFF ST
Mailing Address - Street 2:SUITE 550
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-4894
Mailing Address - Country:US
Mailing Address - Phone:435-628-6200
Mailing Address - Fax:435-652-9051
Practice Address - Street 1:1091 N BLUFF ST
Practice Address - Street 2:SUITE 550
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-4894
Practice Address - Country:US
Practice Address - Phone:435-628-6200
Practice Address - Fax:435-652-9051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT936674399211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty