Basic Information
| Provider Information | |||||||||
| NPI: | 1144577628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BECKER | ||||||||
| FirstName: | AUTUMN | ||||||||
| MiddleName: | LEIGH-ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EDWARDS | ||||||||
| OtherFirstName: | AUTUMN | ||||||||
| OtherMiddleName: | LEIGH-ANN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2817 REILLY ST | ||||||||
| Address2: | US ARMY DENTAL ACTIVITY | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283107324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106432196 | ||||||||
| FaxNumber: | 9109077904 | ||||||||
| Practice Location | |||||||||
| Address1: | 2817 REILLY ST | ||||||||
| Address2: | US ARMY DENTAL ACTIVITY | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283107324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106432196 | ||||||||
| FaxNumber: | 9109077904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2012 | ||||||||
| LastUpdateDate: | 05/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 60871 | KS | Y | Dental Providers | Dentist | General Practice |
No ID Information.