Provider Demographics
NPI:1609888502
Name:TEITELBAUM, BENJAMIN DAVID (DOM)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:DAVID
Last Name:TEITELBAUM
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2068
Mailing Address - Street 2:
Mailing Address - City:EL PRADO
Mailing Address - State:NM
Mailing Address - Zip Code:87529-2068
Mailing Address - Country:US
Mailing Address - Phone:505-776-1067
Mailing Address - Fax:
Practice Address - Street 1:98 STATE ROAD 150
Practice Address - Street 2:SUITE 2, VENADO PLAZA
Practice Address - City:EL PRADO
Practice Address - State:NM
Practice Address - Zip Code:87529
Practice Address - Country:US
Practice Address - Phone:505-776-1067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM369171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist