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NPI Code Detail

MEDICARE: MARY T BENJAMIN DDS

MEDICARE: MARY T BENJAMIN DDS
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
11223D0001XPublic Health DentistryDN010144GA

General Provider Information

NPI Number : 1790743870
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY T BENJAMIN DDS
Provider Business Mailing Address
First Line : PO BOX 897
Second Line : 2570 RIVERSIDE PARKWAY
City : LAWRENCEVILLE
State : GA
Zip : 30046-0897
Country : US
Telephone Number : 770-339-4260
Fax Number : 770-963-6322
Provider Business Practice Location Address
First Line : 15 S CLAYTON ST
Second Line :
City : LAWRENCEVILLE
State : GA
Zip : 30045-5715
Country : US
Telephone Number : 770-339-4283
Fax Number : 770-279-5983
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/01/2006
Last Update Date : 07/08/2007

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