Provider Demographics
NPI:1689083347
Name:TIMOTHY A. BENICH DDS, PC
Entity Type:Organization
Organization Name:TIMOTHY A. BENICH DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-924-0157
Mailing Address - Street 1:6304 OLD HIGHWAY 5
Mailing Address - Street 2:100
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-2452
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6304 OLD HIGHWAY 5
Practice Address - Street 2:100
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-2452
Practice Address - Country:US
Practice Address - Phone:770-924-0157
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7987305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization