Healthcare Provider Details

I. General information

NPI: 1700840386
Provider Name (Legal Business Name): BENJAMIN PATRICK LARRABEE DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 S CRISMON RD SUITE 183
MESA AZ
85209-3717
US

IV. Provider business mailing address

1810 S CRISMON RD STE 183
MESA AZ
85209-3717
US

V. Phone/Fax

Practice location:
  • Phone: 480-357-4900
  • Fax: 480-357-4904
Mailing address:
  • Phone: 480-357-4900
  • Fax: 480-357-4904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD6671
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: