Healthcare Provider Details

I. General information

NPI: 1336792423
Provider Name (Legal Business Name): BENJAMIN HOSTETTER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 S IDAHO RD STE 100
APACHE JUNCTION AZ
85119-0006
US

IV. Provider business mailing address

7445 E EAGLE CREST DR UNIT 2055
MESA AZ
85207-7154
US

V. Phone/Fax

Practice location:
  • Phone: 970-290-1028
  • Fax:
Mailing address:
  • Phone: 970-290-1028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7556
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD010900
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: