Provider Demographics
NPI:1003981002
Name:SEYMOUR, BENJAMIN JARVIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JARVIS
Last Name:SEYMOUR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 HAYNES ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-1809
Mailing Address - Country:US
Mailing Address - Phone:231-775-6531
Mailing Address - Fax:231-775-6431
Practice Address - Street 1:504 HAYNES ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-1809
Practice Address - Country:US
Practice Address - Phone:231-775-6531
Practice Address - Fax:231-775-6431
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010-194031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4918174OtherMEDICAID
MI4919510OtherMEDICAID
MI4919500OtherMEDICAID
MID194030OtherBCBS
MI1883242OtherUNITED CONCORDIA