Healthcare Provider Details

I. General information

NPI: 1114545043
Provider Name (Legal Business Name): BENJAMIN RUSSELL HOBAICA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1353 DORCHESTER AVE
DORCHESTER MA
02122-2932
US

IV. Provider business mailing address

3956 CLEARY RD
CLINTON NY
13323-4112
US

V. Phone/Fax

Practice location:
  • Phone: 617-288-3230
  • Fax:
Mailing address:
  • Phone: 315-796-0492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1859024
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: