Provider Demographics
NPI:1003116617
Name:BENJAMIN, DALE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W HURON ST # 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1304
Mailing Address - Country:US
Mailing Address - Phone:352-284-4164
Mailing Address - Fax:
Practice Address - Street 1:6020 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1108
Practice Address - Country:US
Practice Address - Phone:773-237-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028101122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist