Provider Demographics
NPI:1043340300
Name:VIZCONDE, BENITO O (DMD)
Entity Type:Individual
Prefix:DR
First Name:BENITO
Middle Name:O
Last Name:VIZCONDE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5771 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-2044
Mailing Address - Country:US
Mailing Address - Phone:714-228-1230
Mailing Address - Fax:714-228-0580
Practice Address - Street 1:5771 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-2044
Practice Address - Country:US
Practice Address - Phone:714-228-1230
Practice Address - Fax:714-228-0580
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice