Healthcare Provider Details

I. General information

NPI: 1487208310
Provider Name (Legal Business Name): CHARLES ALFRED BENAVIDEZ SR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8007 LAGUNA BLVD STE 3
ELK GROVE CA
95758-8127
US

IV. Provider business mailing address

8007 LAGUNA BLVD STE 3
ELK GROVE CA
95758-8127
US

V. Phone/Fax

Practice location:
  • Phone: 916-683-3011
  • Fax:
Mailing address:
  • Phone: 916-683-3011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number42805
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: