Healthcare Provider Details

I. General information

NPI: 1376112433
Provider Name (Legal Business Name): BREANNA MARJORIE BENBOW DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 JEFFERSON ST
WHITEVILLE NC
28472-3602
US

IV. Provider business mailing address

PO BOX 810
WHITEVILLE NC
28472-0810
US

V. Phone/Fax

Practice location:
  • Phone: 910-640-6615
  • Fax:
Mailing address:
  • Phone: 910-640-6615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12218
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12218
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number12218
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: