Healthcare Provider Details

I. General information

NPI: 1124958798
Provider Name (Legal Business Name): BENJAMIN JARVIS PASSEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 PONTE MORINO DR
CAMERON PARK CA
95682-7432
US

IV. Provider business mailing address

13325 S ENSIGN POINT LN APT 6204
DRAPER UT
84020-8002
US

V. Phone/Fax

Practice location:
  • Phone: 530-621-7700
  • Fax:
Mailing address:
  • Phone: 208-803-8613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number112964
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: