Provider Demographics
NPI:1881373926
Name:WASSON, BENJAMIN MICHAEL
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MICHAEL
Last Name:WASSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6976 SW 39TH ST APT 203
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-2455
Mailing Address - Country:US
Mailing Address - Phone:828-989-1387
Mailing Address - Fax:
Practice Address - Street 1:7800 W SAND LAKE RD STE 220
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5198
Practice Address - Country:US
Practice Address - Phone:407-934-0804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28267122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist