Provider Demographics
NPI:1275614216
Name:BENJAMIN, MAUZARD (DDS)
Entity Type:Individual
Prefix:
First Name:MAUZARD
Middle Name:
Last Name:BENJAMIN
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 1:157 N MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4565
Mailing Address - Country:US
Mailing Address - Phone:757-925-1866
Mailing Address - Fax:757-247-0951
Practice Address - Street 1:157 N MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4565
Practice Address - Country:US
Practice Address - Phone:757-925-1866
Practice Address - Fax:757-247-0951
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014117511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice