Provider Demographics
NPI:1124870225
Name:BENAVIDES, LUIS
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:BENAVIDES
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 1:710 E SAN YSIDRO BLVD STE 128
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-3123
Mailing Address - Country:US
Mailing Address - Phone:619-831-0437
Mailing Address - Fax:619-785-3404
Practice Address - Street 1:506 SHILOH DR APT 2
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78045-6715
Practice Address - Country:US
Practice Address - Phone:619-831-0437
Practice Address - Fax:619-785-3404
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ17925351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice