Benjamin Earl Dewaal, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

2011017964 Issued in MO

Practice address

1 Southtowne Dr
Potosi, MO 63664-5729

Phone

(573) 438-8401

Fax

(573) 438-8402

NPI assigned

Jun 20, 2011

Last updated

Jun 20, 2011By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MO

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Great Mines Health Center

  • Federally Qualified Health Center (FQHC)
  • Potosi, MO
  • NPI 1376536953
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1308528000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1308528000000",
    "number": "1801182704",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 SOUTHTOWNE DR",
            "city": "POTOSI",
            "state": "MO",
            "postal_code": "636645729",
            "telephone_number": "573-438-8401",
            "fax_number": "573-438-8402"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 SOUTHTOWNE DR",
            "city": "POTOSI",
            "state": "MO",
            "postal_code": "636645729",
            "telephone_number": "573-438-8401",
            "fax_number": "573-438-8402"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DEWAAL",
        "first_name": "BENJAMIN",
        "middle_name": "EARL",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2011-06-20",
        "last_updated": "2011-06-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MO",
            "license": "2011017964",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Angela S Declue, FNP
• Daeton Degrant, LPC
• Walter R Dellenbaugh, RPH
• Melissa Derousse
• Developmental Disabilities Council of Washington Co Inc
• Dr. Gregory K. Terpstra D.O., Family Practice, L.L.C.
• Tessa Dunivan
• Steven D Ebers, MD
• Charlotte Ann Edelen, LCSW
• Edward William Lake DDS PC

• General Practice Dentistry in Potosi, MO
• Providers in Potosi, MO by specialty
• General Practice Dentistry in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 20, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.