Healthcare Provider Details

I. General information

NPI: 1063598167
Provider Name (Legal Business Name): BENTON JAMES RUNQUIST D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 ANDERSON RD SUITE #6
DAVIS CA
95616-3505
US

IV. Provider business mailing address

307 GRANDE AVE
DAVIS CA
95616-0211
US

V. Phone/Fax

Practice location:
  • Phone: 530-756-0220
  • Fax: 530-758-3796
Mailing address:
  • Phone: 530-757-6780
  • Fax: 530-758-3796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number33843
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: