Healthcare Provider Details

I. General information

NPI: 1003431123
Provider Name (Legal Business Name): BENJAMIN NICOLAS CUEVAS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 STARLITE DR
KINGFISHER OK
73750-4944
US

IV. Provider business mailing address

100 STARLITE DR
KINGFISHER OK
73750-4944
US

V. Phone/Fax

Practice location:
  • Phone: 405-375-5855
  • Fax:
Mailing address:
  • Phone: 405-375-5855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberT-7293
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: