Healthcare Provider Details

I. General information

NPI: 1164141099
Provider Name (Legal Business Name): BENJAMIN DAVID VORPAHL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 08/24/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 W COOK ST
PORTAGE WI
53901-2106
US

IV. Provider business mailing address

260 W COOK ST
PORTAGE WI
53901-2106
US

V. Phone/Fax

Practice location:
  • Phone: 608-742-2331
  • Fax:
Mailing address:
  • Phone: 608-742-2331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6001073-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: