Provider Demographics
NPI:1043374176
Name:12TH STREET DENTAL OFFICE PA
Entity type:Organization
Organization Name:12TH STREET DENTAL OFFICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PARTNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-282-6448
Mailing Address - Street 1:1008 12TH STREET SE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-5030
Mailing Address - Country:US
Mailing Address - Phone:507-282-6448
Mailing Address - Fax:507-287-8846
Practice Address - Street 1:1008 12TH STREET SE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-5030
Practice Address - Country:US
Practice Address - Phone:507-282-6448
Practice Address - Fax:507-287-8846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN9567122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty