Provider Demographics
NPI:1528210853
Name:GEORGE, BENOY KANNIKATTEL (BDS, DDS)
Entity Type:Individual
Prefix:DR
First Name:BENOY
Middle Name:KANNIKATTEL
Last Name:GEORGE
Suffix:
Gender:M
Credentials:BDS, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 DEKOVEN DR
Mailing Address - Street 2:APT 1009
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3403
Mailing Address - Country:US
Mailing Address - Phone:631-487-5895
Mailing Address - Fax:
Practice Address - Street 1:685 QUEEN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-1547
Practice Address - Country:US
Practice Address - Phone:860-924-1615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104561223P0700X
CT108391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice