Provider Demographics
NPI:1538236708
Name:MIBAB, BEN (DDS MS)
Entity type:Individual
Prefix:DR
First Name:BEN
Middle Name:
Last Name:MIBAB
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 OLD ALABAMA RD
Mailing Address - Street 2:SUITE 6000
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30022-8594
Mailing Address - Country:US
Mailing Address - Phone:770-552-6800
Mailing Address - Fax:
Practice Address - Street 1:3005 OLD ALABAMA RD
Practice Address - Street 2:SUITE 6000
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30022-8594
Practice Address - Country:US
Practice Address - Phone:770-552-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 105001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics