Provider Demographics
NPI:1487208310
Name:BENAVIDEZ, CHARLES ALFRED SR (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALFRED
Last Name:BENAVIDEZ
Suffix:SR
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 1:8007 LAGUNA BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-8127
Mailing Address - Country:US
Mailing Address - Phone:916-683-3011
Mailing Address - Fax:
Practice Address - Street 1:8007 LAGUNA BLVD STE 3
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-8127
Practice Address - Country:US
Practice Address - Phone:916-683-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA428051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice