Provider Demographics
NPI:1205685047
Name:BENSON, BROCK
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:BENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42014 CAMINO CASANA
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-6359
Mailing Address - Country:US
Mailing Address - Phone:951-719-7173
Mailing Address - Fax:
Practice Address - Street 1:3999 N GLOSTER ST STE D
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-0950
Practice Address - Country:US
Practice Address - Phone:662-778-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS4447-241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program