Provider Demographics
NPI:1588958375
Name:BENJAMIN, GARY (DMD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:BENJAMIN
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 1:4114 MEDICAL DR
Mailing Address - Street 2:APT 19306
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-5607
Mailing Address - Country:US
Mailing Address - Phone:352-281-8344
Mailing Address - Fax:
Practice Address - Street 1:8410 DATAPOINT DR
Practice Address - Street 2:3RD FLOOR AEGD
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3220
Practice Address - Country:US
Practice Address - Phone:201-949-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN193201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice