Provider Demographics
NPI:1104437565
Name:BECKMAN, KELLI ANN
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:BECKMAN
Suffix:
Gender:F
Credentials:
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 46
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:WA
Mailing Address - Zip Code:98345-0046
Mailing Address - Country:US
Mailing Address - Phone:206-745-3808
Mailing Address - Fax:206-745-3811
Practice Address - Street 1:1141 BEACH DR E
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-4937
Practice Address - Country:US
Practice Address - Phone:206-745-3808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60172005124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist