Provider Demographics
NPI:1053880377
Name:BENZ, ROBERTA DEE
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:DEE
Last Name:BENZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 LAKE WOODMOOR DR
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-9074
Mailing Address - Country:US
Mailing Address - Phone:719-488-3014
Mailing Address - Fax:719-488-3015
Practice Address - Street 1:1777 LAKE WOODMOOR DR
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-9074
Practice Address - Country:US
Practice Address - Phone:719-488-3014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH000201302124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist