Provider Demographics
NPI:1811380983
Name:BENJAMIN N. DILLER, DDS, PA
Entity Type:Organization
Organization Name:BENJAMIN N. DILLER, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:N
Authorized Official - Last Name:DILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-509-6865
Mailing Address - Street 1:1200 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3043
Mailing Address - Country:US
Mailing Address - Phone:904-261-0851
Mailing Address - Fax:904-261-5002
Practice Address - Street 1:1200 S 14TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3043
Practice Address - Country:US
Practice Address - Phone:904-261-0851
Practice Address - Fax:904-261-5002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21074261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental