1417487513 NPI number — DR. BENJAMIN ANDREW KORDUSKY DDS, MS

Table of content: DR. BENJAMIN ANDREW KORDUSKY DDS, MS (NPI 1417487513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417487513 NPI number — DR. BENJAMIN ANDREW KORDUSKY DDS, MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KORDUSKY
Provider First Name:
BENJAMIN
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS, MS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417487513
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
45 FAIRFIELD MNR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGANTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26505-8011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8415 ELK GROVE BLVD BLDG B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELK GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95758-9573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-755-6213
Provider Business Practice Location Address Fax Number:
916-755-6214
Provider Enumeration Date:
06/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0700X , with the licence number:  4269 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0700X , with the licence number: 106157 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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