Provider Demographics
NPI:1083791826
Name:BENICH, TIMOTHY A (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:A
Last Name:BENICH
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 1:459 SHADOWLAWN RD SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-4326
Mailing Address - Country:US
Mailing Address - Phone:770-953-3143
Mailing Address - Fax:
Practice Address - Street 1:135 JOHNSON FERRY RD
Practice Address - Street 2:STE 2100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4942
Practice Address - Country:US
Practice Address - Phone:770-953-3143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA79871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice