Provider Demographics
NPI:1205186525
Name:BENAGE, MARK A (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:BENAGE
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 1:5955 ZEAMER AVENUE
Mailing Address - Street 2:673D MDG
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506-3700
Mailing Address - Country:US
Mailing Address - Phone:907-580-5020
Mailing Address - Fax:
Practice Address - Street 1:5955 ZEAMER AVENUE
Practice Address - Street 2:673D MDG
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506-3700
Practice Address - Country:US
Practice Address - Phone:907-580-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28116122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist