Provider Demographics
NPI:1558416065
Name:TARSITANO, BEN F (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:BEN
Middle Name:F
Last Name:TARSITANO
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:70 PENNY LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-6020
Mailing Address - Country:US
Mailing Address - Phone:831-722-8887
Mailing Address - Fax:831-722-2762
Practice Address - Street 1:70 PENNY LN
Practice Address - Street 2:SUITE B
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-6020
Practice Address - Country:US
Practice Address - Phone:831-722-8887
Practice Address - Fax:831-722-2762
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA288221223S0112X
CAA50488204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A504880Medicaid
CA00A504880Medicaid
CAU19243Medicare UPIN