Provider Demographics
NPI:1932367729
Name:FRAGALE, BENJAMIN (DMD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:FRAGALE
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 1:2408 WEST PLAZA DRIVE
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308
Mailing Address - Country:US
Mailing Address - Phone:850-597-9174
Mailing Address - Fax:850-597-9175
Practice Address - Street 1:2408 WEST PLAZA DR STE A
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-597-9174
Practice Address - Fax:850-597-9175
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN176611223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics