Provider Demographics
NPI:1134720337
Name:TEXAS WISDOM TEETH SPECIALISTS
Entity type:Organization
Organization Name:TEXAS WISDOM TEETH SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENAGE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-786-4307
Mailing Address - Street 1:129 CIRCLE CLUB LN
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75602-4866
Mailing Address - Country:US
Mailing Address - Phone:903-445-2433
Mailing Address - Fax:
Practice Address - Street 1:8409 W CLEBURNE RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-1421
Practice Address - Country:US
Practice Address - Phone:214-814-1057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-04
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty