Basic Information
| Provider Information | |||||||||
| NPI: | 1740264753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENYAMINOV | ||||||||
| FirstName: | GENNADIY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 OCEANA DR W | ||||||||
| Address2: | #3-C | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187438012 | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 ROBERT PITT DR | ||||||||
| Address2: | |||||||||
| City: | MONSEY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109523333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453526800 | ||||||||
| FaxNumber: | 8457703847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 06/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 485791 | NY | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 02129266 | 05 | NY | MEDICAID |