Provider Demographics
NPI:1093785222
Name:MAGLEBY, BENJAMIN MITHRANDIR
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:MITHRANDIR
Last Name:MAGLEBY
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 1:142 PLOW POINT LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-9591
Mailing Address - Country:US
Mailing Address - Phone:650-305-9922
Mailing Address - Fax:
Practice Address - Street 1:142 PLOW POINT LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-9591
Practice Address - Country:US
Practice Address - Phone:650-305-9922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA538281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice