Provider Demographics
NPI:1881072064
Name:POTTER, BENNY L (DDS)
Entity type:Individual
Prefix:MR
First Name:BENNY
Middle Name:L
Last Name:POTTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:BEN
Other - Middle Name:L
Other - Last Name:POTTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:4341 SE 15TH ST,
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115
Mailing Address - Country:US
Mailing Address - Phone:405-670-3800
Mailing Address - Fax:
Practice Address - Street 1:4341 SE 15TH ST
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115
Practice Address - Country:US
Practice Address - Phone:405-670-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK47921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice