Healthcare Provider Details

I. General information

NPI: 1205930765
Provider Name (Legal Business Name): KENNETH J. BENSON, DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2081 SHEPERDS VINEYARD DR
APEX NC
27502-6410
US

IV. Provider business mailing address

2081 SHEPERDS VINEYARD DR
APEX NC
27502-6410
US

V. Phone/Fax

Practice location:
  • Phone: 919-387-3388
  • Fax: 919-387-0070
Mailing address:
  • Phone: 919-387-3388
  • Fax: 919-387-0070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number6621
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier902VT
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS
# 2
Identifier89022VT
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 3
Identifier6621
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerDENTAL LICENSE

VIII. Authorized Official

Name: DR. KENNETH J. BENSON
Title or Position: OWNER
Credential: DDS
Phone: 919-387-3388