Provider Demographics
NPI:1710232061
Name:BENJAMIN, LAURA ELISE (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ELISE
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ELISE
Other - Last Name:STEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4114 MEDICAL DR APT 19306
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-6076
Mailing Address - Country:US
Mailing Address - Phone:561-951-3797
Mailing Address - Fax:
Practice Address - Street 1:3829 LOCKHILL SELMA RD.
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230
Practice Address - Country:US
Practice Address - Phone:210-366-3606
Practice Address - Fax:210-366-0052
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-23
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28260122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710232061OtherNA