Basic Information
| Provider Information | |||||||||
| NPI: | 1376962688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENS | ||||||||
| FirstName: | SEBASTIAAN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7623 KAYWOOD DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752094007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124841167 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2450 ATLANTA HWY STE 903 | ||||||||
| Address2: | |||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300401252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046595909 | ||||||||
| FaxNumber: | 7703999449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | R3273 | TX | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 79891 | GA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 003211857A | 05 | GA | MEDICAID |