Provider Demographics
NPI:1568697654
Name:ABT, BENJAMIN ROBERT (DMD, MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ROBERT
Last Name:ABT
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5415 DISTINCTION WAY
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-8438
Mailing Address - Country:US
Mailing Address - Phone:928-350-8045
Mailing Address - Fax:
Practice Address - Street 1:5415 DISTINCTION WAY
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-8438
Practice Address - Country:US
Practice Address - Phone:928-350-8045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL57931223S0112X
AZ89111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program