Provider Demographics
NPI:1639757644
Name:BENJAMEN, MARY (DDS)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:BENJAMEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 W 124TH ST FL 9
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-4919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:158 W 124TH ST FL 9
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-4919
Practice Address - Country:US
Practice Address - Phone:212-523-6500
Practice Address - Fax:212-523-5677
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0626211223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program