Provider Demographics
NPI:1902119720
Name:SYNDERGAARD, BENJAMIN (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:SYNDERGAARD
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703-3746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1675 VISTA LN
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-4640
Practice Address - Country:US
Practice Address - Phone:775-882-3033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8859122300000X
NVS4-841223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist