Healthcare Provider Details

I. General information

NPI: 1457877458
Provider Name (Legal Business Name): BENJAMIN ATLAS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2017
Last Update Date: 06/14/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2575
US

IV. Provider business mailing address

34800 BOB WILSON DR
SAN DIEGO CA
92134-5000
US

V. Phone/Fax

Practice location:
  • Phone: 760-519-4801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS101670
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12691
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: