Provider Demographics
NPI:1215029368
Name:BENCIVENGO, CHARLES J (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:BENCIVENGO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-6254
Mailing Address - Country:US
Mailing Address - Phone:860-582-8095
Mailing Address - Fax:860-589-3615
Practice Address - Street 1:21 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-6254
Practice Address - Country:US
Practice Address - Phone:860-582-8095
Practice Address - Fax:860-589-3615
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT49451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice