Healthcare Provider Details

I. General information

NPI: 1982902821
Provider Name (Legal Business Name): BENJAMIN THOMAS BARBETTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202
US

IV. Provider business mailing address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number2901022095
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number4301113606
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: