=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811380983
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BENJAMIN N. DILLER, DDS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2015
-----------------------------------------------------
Last Update Date | 03/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 S 14TH ST
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-3043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-261-0851
-----------------------------------------------------
Fax | 904-261-5002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 S 14TH ST
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-3043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-261-0851
-----------------------------------------------------
Fax | 904-261-5002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BENJAMIN N DILLER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 419-509-6865
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | DN21074
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------