Provider Demographics
NPI:1619357159
Name:UNDERWOOD, BENJAMIN (DDS)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:UNDERWOOD
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 1:675 WORTHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1561
Mailing Address - Country:US
Mailing Address - Phone:734-306-6061
Mailing Address - Fax:
Practice Address - Street 1:6213 CHICAGO RD
Practice Address - Street 2:100
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-1697
Practice Address - Country:US
Practice Address - Phone:586-264-5410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-30
Last Update Date:2015-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021514122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist