Provider Demographics
NPI:1932491727
Name:FONKE, BENJAMIN DANIEL (DC)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:DANIEL
Last Name:FONKE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 NEW GARDEN RD STE 204
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-2568
Mailing Address - Country:US
Mailing Address - Phone:336-545-3132
Mailing Address - Fax:336-545-0571
Practice Address - Street 1:2006 NEW GARDEN RD STE 204
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2568
Practice Address - Country:US
Practice Address - Phone:336-545-3132
Practice Address - Fax:336-545-0571
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4172111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor