Provider Demographics
NPI:1720106768
Name:CARRICO, BENJAMIN LEE (DMD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:LEE
Last Name:CARRICO
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 1:95 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STRATTANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16258-1903
Mailing Address - Country:US
Mailing Address - Phone:814-980-4021
Mailing Address - Fax:814-764-6173
Practice Address - Street 1:95 MAIN ST
Practice Address - Street 2:
Practice Address - City:STRATTANVILLE
Practice Address - State:PA
Practice Address - Zip Code:16258-1903
Practice Address - Country:US
Practice Address - Phone:814-980-4021
Practice Address - Fax:814-764-6173
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0365531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice