Provider Demographics
NPI:1073801510
Name:DILLER, BENJAMIN NOLAN (DDS)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:NOLAN
Last Name:DILLER
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 1:1200 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3043
Mailing Address - Country:US
Mailing Address - Phone:904-261-0851
Mailing Address - Fax:
Practice Address - Street 1:1200 S 14TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3043
Practice Address - Country:US
Practice Address - Phone:904-261-0851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0234361223G0001X
FLDN210741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice