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General NPI Number Information
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NPI Number | 1417487513
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Entity Type | Individual
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Provider Name | BENJAMIN ANDREW KORDUSKY DDS, MS
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Gender | Male
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Dates
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Enumeration Date | 06/13/2017
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Last Update Date | 06/28/2022
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Provider Practice Location Address
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Address Line | 8415 ELK GROVE BLVD BLDG B
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City | ELK GROVE
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State | CA
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Zip | 95758-9573
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Country | US
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Telephone | 916-755-6213
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Fax | 916-755-6214
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Provider Business Mailing Address
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Address Line | 45 FAIRFIELD MNR
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City | MORGANTOWN
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State | WV
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Zip | 26505-8011
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Country | US
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Telephone |
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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 | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 4269
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 106157
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License Number State | CA
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