Provider Demographics
NPI:1851161145
Name:PHAN, BENJAMIN (DDS)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:PHAN
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 1:6621 WOODSIDE CT E
Mailing Address - Street 2:
Mailing Address - City:THEODORE
Mailing Address - State:AL
Mailing Address - Zip Code:36582-6067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1651 SCHILLINGER RD N
Practice Address - Street 2:
Practice Address - City:SEMMES
Practice Address - State:AL
Practice Address - Zip Code:36575-7409
Practice Address - Country:US
Practice Address - Phone:251-706-7960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD.007267-C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice