Provider Demographics
NPI:1730828369
Name:PETRY, BENJAMIN (DDS)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:PETRY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 CRESCENT DR APT 315
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-1076
Mailing Address - Country:US
Mailing Address - Phone:505-850-3407
Mailing Address - Fax:
Practice Address - Street 1:343 N COTNER BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68505-2315
Practice Address - Country:US
Practice Address - Phone:402-466-1914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7809122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist