Provider Demographics
NPI:1043059801
Name:MOORE, BENJAMIN LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:LEE
Last Name:MOORE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14058 SILVEROD ST NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3667
Mailing Address - Country:US
Mailing Address - Phone:715-862-2446
Mailing Address - Fax:
Practice Address - Street 1:1596 2ND AVE NE STE A
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-8069
Practice Address - Country:US
Practice Address - Phone:763-689-5699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND15062122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist