Provider Demographics
NPI:1093175507
Name:BENN, DOUGLAS (DDS, PHD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:BENN
Suffix:
Gender:M
Credentials:DDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 LEAVENWORTH CT
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-1200
Mailing Address - Country:US
Mailing Address - Phone:402-953-6264
Mailing Address - Fax:
Practice Address - Street 1:3610 LEAVENWORTH CT
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1200
Practice Address - Country:US
Practice Address - Phone:402-953-6264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE69091223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology