Provider Demographics
NPI:1801182704
Name:DEWAAL, BENJAMIN EARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:EARL
Last Name:DEWAAL
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 1:1 SOUTHTOWNE DR
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-5729
Mailing Address - Country:US
Mailing Address - Phone:573-438-8401
Mailing Address - Fax:573-438-8402
Practice Address - Street 1:1 SOUTHTOWNE DR
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-5729
Practice Address - Country:US
Practice Address - Phone:573-438-8401
Practice Address - Fax:573-438-8402
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110179641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice