Provider Demographics
NPI:1487832341
Name:BRUCE C. BENEDICTSON, D.D.S. PA
Entity Type:Organization
Organization Name:BRUCE C. BENEDICTSON, D.D.S. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:BENEDICTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:386-253-1272
Mailing Address - Street 1:222 OAKRIDGE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-4030
Mailing Address - Country:US
Mailing Address - Phone:386-253-1272
Mailing Address - Fax:
Practice Address - Street 1:222 OAKRIDGE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32118-4030
Practice Address - Country:US
Practice Address - Phone:386-253-1272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-03
Last Update Date:2008-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7660261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental