Provider Demographics
NPI:1144518754
Name:COREY, BENJAMIN FREDRIC (RDHAP)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:FREDRIC
Last Name:COREY
Suffix:
Gender:M
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-4607
Mailing Address - Country:US
Mailing Address - Phone:626-755-0003
Mailing Address - Fax:562-491-4999
Practice Address - Street 1:737 E 8TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-4607
Practice Address - Country:US
Practice Address - Phone:626-755-0003
Practice Address - Fax:562-491-4999
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-16
Last Update Date:2011-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP 358124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist