Provider Demographics
NPI:1053935841
Name:ALVERSON, BENJAMIN WADE (DMD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:WADE
Last Name:ALVERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4130 MELROSE DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-1558
Mailing Address - Country:US
Mailing Address - Phone:706-844-4957
Mailing Address - Fax:
Practice Address - Street 1:113 PLANTATION AVE
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2371
Practice Address - Country:US
Practice Address - Phone:770-748-7736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN016034122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist