Provider Demographics
NPI:1104207455
Name:BENITO, BRIAN ADAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ADAM
Last Name:BENITO
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 1:707 E CALTON RD
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-3638
Mailing Address - Country:US
Mailing Address - Phone:956-723-5533
Mailing Address - Fax:
Practice Address - Street 1:707 E CALTON RD
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-3638
Practice Address - Country:US
Practice Address - Phone:956-723-5533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-12
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX309501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice