Provider Demographics
NPI:1063598167
Name:RUNQUIST, BENTON JAMES (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:BENTON
Middle Name:JAMES
Last Name:RUNQUIST
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:307 GRANDE AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-0211
Mailing Address - Country:US
Mailing Address - Phone:530-757-6780
Mailing Address - Fax:530-758-3796
Practice Address - Street 1:635 ANDERSON RD
Practice Address - Street 2:SUITE #6
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-3505
Practice Address - Country:US
Practice Address - Phone:530-756-0220
Practice Address - Fax:530-758-3796
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA338431223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics