Provider Demographics
NPI:1053864637
Name:BENIWAL, SHIVENDER
Entity Type:Individual
Prefix:
First Name:SHIVENDER
Middle Name:
Last Name:BENIWAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 WATER ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-5478
Mailing Address - Country:US
Mailing Address - Phone:978-319-6614
Mailing Address - Fax:
Practice Address - Street 1:130 WATER ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-5478
Practice Address - Country:US
Practice Address - Phone:978-319-6614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18573691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice