Basic Information
Provider Information
NPI: 1003002775
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FLEMING
FirstName: BENJAMIN
MiddleName: RYAN
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 14 LOCKWOOD DR
Address2: SUITE A
City: CHARLESTON
State: SC
PostalCode: 294011126
CountryCode: US
TelephoneNumber: 8437228500
FaxNumber: 8437208555
Practice Location
Address1: 14 LOCKWOOD DR
Address2: SUITE A
City: CHARLESTON
State: SC
PostalCode: 294011126
CountryCode: US
TelephoneNumber: 8437228500
FaxNumber: 8437208555
Other Information
ProviderEnumerationDate: 09/17/2007
LastUpdateDate: 08/09/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X4689SCY Dental ProvidersDentist 
122300000X30-022559OHN Dental ProvidersDentist 

No ID Information.


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