Provider Demographics
NPI:1427271311
Name:BECKETT, GARY MELVIN (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:MELVIN
Last Name:BECKETT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:944 HUMPHREY ST
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907-1407
Mailing Address - Country:US
Mailing Address - Phone:617-928-7360
Mailing Address - Fax:617-928-7030
Practice Address - Street 1:777 DEDHAM ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459-3323
Practice Address - Country:US
Practice Address - Phone:617-928-7360
Practice Address - Fax:617-928-7030
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA151111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0260169Medicaid