Provider Demographics
NPI:1295275642
Name:BENLULU, MIKAELA (DDS)
Entity type:Individual
Prefix:DR
First Name:MIKAELA
Middle Name:
Last Name:BENLULU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:MIKAELA
Other - Middle Name:
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:639 E OCEAN AVE STE 409
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-5017
Mailing Address - Country:US
Mailing Address - Phone:561-735-6553
Mailing Address - Fax:
Practice Address - Street 1:2623 S SEACREST BLVD STE 112
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-7531
Practice Address - Country:US
Practice Address - Phone:561-810-8790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1037481223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program