Provider Demographics
NPI:1295782324
Name:PECK, BENJAMIN BEREK (DMD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:BEREK
Last Name:PECK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 100
Mailing Address - Street 2:
Mailing Address - City:ATCO
Mailing Address - State:NJ
Mailing Address - Zip Code:08004-0100
Mailing Address - Country:US
Mailing Address - Phone:856-767-6400
Mailing Address - Fax:856-767-8609
Practice Address - Street 1:311 WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:ATCO
Practice Address - State:NJ
Practice Address - Zip Code:08004-2230
Practice Address - Country:US
Practice Address - Phone:856-767-6400
Practice Address - Fax:856-767-8609
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ10753122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ116600-01Medicaid