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General NPI Number Information
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NPI Number | 1366262701
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Entity Type | Organization
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Legal Business Name | KING BENJAMIN DENTAL PLLC
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Dates
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Enumeration Date | 10/11/2024
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Last Update Date | 10/11/2024
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Provider Practice Location Address
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Address Line | 3467 PINE RIDGE RD STE 101
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City | NAPLES
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State | FL
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Zip | 34109-3832
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Country | US
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Telephone | 239-251-5045
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Fax |
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Provider Business Mailing Address
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Address Line | 18589 SARASOTA RD
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City | FORT MYERS
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State | FL
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Zip | 33967-3520
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Country | US
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Telephone | 239-240-5886
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | BRADLY MOURITSEN
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Credential |
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Telephone | 239-251-5045
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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