Healthcare Provider Details

I. General information

NPI: 1417487513
Provider Name (Legal Business Name): BENJAMIN ANDREW KORDUSKY DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8415 ELK GROVE BLVD BLDG B
ELK GROVE CA
95758-9573
US

IV. Provider business mailing address

45 FAIRFIELD MNR
MORGANTOWN WV
26505-8011
US

V. Phone/Fax

Practice location:
  • Phone: 916-755-6213
  • Fax: 916-755-6214
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number4269
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number106157
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: