Provider Demographics
NPI:1447318787
Name:BECKER, JAKE DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:JAKE
Middle Name:DAVID
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:PO BOX 435
Mailing Address - Street 2:
Mailing Address - City:HINES
Mailing Address - State:OR
Mailing Address - Zip Code:97738-0435
Mailing Address - Country:US
Mailing Address - Phone:541-573-3838
Mailing Address - Fax:
Practice Address - Street 1:555 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:BURNS
Practice Address - State:OR
Practice Address - Zip Code:97720-1408
Practice Address - Country:US
Practice Address - Phone:541-573-7778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8786122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278318Medicaid