Healthcare Provider Details

I. General information

NPI: 1093289647
Provider Name (Legal Business Name): BENJAMIN JONAH STATMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 07/01/2022
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 SCHROCK RD STE 201
COLUMBUS OH
43229-1179
US

IV. Provider business mailing address

4486 BAINTREE RD
UNIVERSITY HEIGHTS OH
44118-3933
US

V. Phone/Fax

Practice location:
  • Phone: 614-401-4415
  • Fax:
Mailing address:
  • Phone: 818-618-3663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number30.026729
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30.026729
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: