Healthcare Provider Details

I. General information

NPI: 1144292830
Provider Name (Legal Business Name): BENJAMIN JOHN FRAVEL D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CRESTVIEW DR SUITE 3
HUDSON WI
54016-9366
US

IV. Provider business mailing address

1200 CRESTVIEW DR SUITE 3
HUDSON WI
54016-9366
US

V. Phone/Fax

Practice location:
  • Phone: 715-386-8070
  • Fax: 715-386-8958
Mailing address:
  • Phone: 715-386-8070
  • Fax: 715-386-8958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD11471
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6081-015
License Number StateWI

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: