Provider Demographics
NPI:1770040412
Name:BENINATI, TYLER ANTHONY (DMD)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:ANTHONY
Last Name:BENINATI
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 1:10928 TRINITY PKWY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-7230
Mailing Address - Country:US
Mailing Address - Phone:209-474-8000
Mailing Address - Fax:
Practice Address - Street 1:7743 WEST LN STE C5
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-3381
Practice Address - Country:US
Practice Address - Phone:209-474-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-01
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1063101223P0221X
RI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program