MEDICARE: DR. CARLOS F BENITEZ D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1702	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	41573	OTHER	PR	SSS
2	041348	OTHER	PR	BLUE CROSS
3	206384	OTHER	PR	UTI
4	7310230	OTHER	PR	HUMANA

General Provider Information

NPI Number	:	1578568598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLOS F BENITEZ D.M.D.

Provider Business Mailing Address
First Line	:	609 AVE TITO CASTRO
Second Line	:	PMB 349
City	:	PONCE
State	:	PR
Zip	:	00716-0206
Country	:	US
Telephone Number	:	787-841-1419
Fax Number	:	787-841-1419

Provider Business Practice Location Address
First Line	:	609 AVE TITO CASTRO
Second Line	:	PMB 349
City	:	PONCE
State	:	PR
Zip	:	00716-0206
Country	:	US
Telephone Number	:	787-841-1419
Fax Number	:	787-841-1419

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	07/08/2007

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