Healthcare Provider Details

I. General information

NPI: 1144518754
Provider Name (Legal Business Name): BENJAMIN FREDRIC COREY RDHAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2011
Last Update Date: 07/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 E 8TH ST
LONG BEACH CA
90813-4607
US

IV. Provider business mailing address

737 E 8TH ST
LONG BEACH CA
90813-4607
US

V. Phone/Fax

Practice location:
  • Phone: 626-755-0003
  • Fax: 562-491-4999
Mailing address:
  • Phone: 626-755-0003
  • Fax: 562-491-4999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberHAP 358
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: