Provider Demographics
NPI:1922538370
Name:GIETZEN, BENJAMIN THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:THOMAS
Last Name:GIETZEN
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 1:3503 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-2353
Mailing Address - Country:US
Mailing Address - Phone:616-490-2498
Mailing Address - Fax:
Practice Address - Street 1:51333 MOUND RD
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48316-4344
Practice Address - Country:US
Practice Address - Phone:586-799-4240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010222491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice