Provider Demographics
NPI:1790743870
Name:BENJAMIN, MARY T (DDS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:BENJAMIN
Suffix:
Gender:F
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:PO BOX 897
Mailing Address - Street 2:2570 RIVERSIDE PARKWAY
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-0897
Mailing Address - Country:US
Mailing Address - Phone:770-339-4260
Mailing Address - Fax:770-963-6322
Practice Address - Street 1:15 S CLAYTON ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-5715
Practice Address - Country:US
Practice Address - Phone:770-339-4283
Practice Address - Fax:770-279-5983
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0101441223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health