Provider Demographics
NPI:1386406999
Name:BELLAVANCE, BENJAMIN NEAL
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:NEAL
Last Name:BELLAVANCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH
Mailing Address - State:MA
Mailing Address - Zip Code:02769-2203
Mailing Address - Country:US
Mailing Address - Phone:774-565-0214
Mailing Address - Fax:
Practice Address - Street 1:23RD DENTAL COMPANY 1591 GRIFFIN ROAD
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278
Practice Address - Country:US
Practice Address - Phone:760-830-7054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QS1000X
UT14231492-9926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health