Provider Demographics
NPI:1154616803
Name:WURTZEL, BENJAMIN M (DDS)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:M
Last Name:WURTZEL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4554 WASHTENAW AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1000
Mailing Address - Country:US
Mailing Address - Phone:734-971-9653
Mailing Address - Fax:
Practice Address - Street 1:4554 WASHTENAW AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1000
Practice Address - Country:US
Practice Address - Phone:734-971-9653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010204551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice