Provider Demographics
NPI:1659494797
Name:PODURGIEL, BENJAMIN JOSEPH JR (DDS)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOSEPH
Last Name:PODURGIEL
Suffix:JR
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 1:30 ATLANTIC AVE
Mailing Address - Street 2:BOX 3111
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-8201
Mailing Address - Country:US
Mailing Address - Phone:860-536-8768
Mailing Address - Fax:
Practice Address - Street 1:727 NORWICH NEW LONDON TPK
Practice Address - Street 2:
Practice Address - City:UNCASVILLE
Practice Address - State:CT
Practice Address - Zip Code:06382-2123
Practice Address - Country:US
Practice Address - Phone:860-848-0662
Practice Address - Fax:860-848-0662
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT35141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice