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General NPI Number Information
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NPI Number | 1255022059
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Entity Type | Individual
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Provider Name | BENTON GERARD WEINACKER
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Gender | Male
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Dates
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Enumeration Date | 05/15/2023
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Last Update Date | 07/27/2023
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Provider Practice Location Address
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Address Line | 1136 FOLLY RD
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City | CHARLESTON
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State | SC
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Zip | 29412-4104
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Country | US
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Telephone | 843-738-1196
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Fax |
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Provider Business Mailing Address
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Address Line | 5425 SPRINGHILL WOODS DR S
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City | MOBILE
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State | AL
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Zip | 36608-0701
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Country | US
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Telephone | 251-586-1331
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DGD10599
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License Number State | SC
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