Healthcare Provider Details

I. General information

NPI: 1790899490
Provider Name (Legal Business Name): JOHN J. BENINATO, D.D.S., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 01/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 JOHN MADDOX DR NW SUITE B
ROME GA
30165-1413
US

IV. Provider business mailing address

21 JOHN MADDOX DR NW SUITE B
ROME GA
30165-1413
US

V. Phone/Fax

Practice location:
  • Phone: 706-234-0718
  • Fax:
Mailing address:
  • Phone: 706-234-0718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number10834
License Number StateGA

VIII. Authorized Official

Name: JOHN J. BENINATO
Title or Position: PRESIDENT/OWNER
Credential: D.D.S.
Phone: 706-234-0718