Provider Demographics
NPI:1588799555
Name:GERKIN, BENJAMIN J (DDS)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:J
Last Name:GERKIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4604 S HARVARD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2912
Mailing Address - Country:US
Mailing Address - Phone:918-749-2509
Mailing Address - Fax:918-749-6486
Practice Address - Street 1:4604 S HARVARD AVE STE A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2912
Practice Address - Country:US
Practice Address - Phone:918-749-2509
Practice Address - Fax:918-749-6486
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK57171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201700722OtherTAX IDENIFICATION NUMBER