Provider Demographics
NPI:1588226567
Name:DONNELLI, BENJAMIN
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:DONNELLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 COMMERCE ST APT 1414
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-4916
Mailing Address - Country:US
Mailing Address - Phone:214-734-5883
Mailing Address - Fax:
Practice Address - Street 1:4433 NAAMAN FOREST BLVD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-2722
Practice Address - Country:US
Practice Address - Phone:214-734-5883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX351831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice