Provider Demographics
NPI:1336170042
Name:BENJAMIN KOREN, D.D.S. III. P.A,
Entity Type:Organization
Organization Name:BENJAMIN KOREN, D.D.S. III. P.A,
Other - Org Name:CREEDMOOR FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:KOREN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-528-4004
Mailing Address - Street 1:110 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CREEDMOOR
Mailing Address - State:NC
Mailing Address - Zip Code:27522-9747
Mailing Address - Country:US
Mailing Address - Phone:919-528-4004
Mailing Address - Fax:919-528-2211
Practice Address - Street 1:110 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:CREEDMOOR
Practice Address - State:NC
Practice Address - Zip Code:27522-9747
Practice Address - Country:US
Practice Address - Phone:919-528-4004
Practice Address - Fax:919-528-2211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6997122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902042Medicaid
NC017JWOtherBCBS GROUP NUMBER