Provider Demographics
NPI:1295467256
Name:BENNING, DEREK JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:JOHN
Last Name:BENNING
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 1:318 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056-1911
Mailing Address - Country:US
Mailing Address - Phone:217-303-8787
Mailing Address - Fax:
Practice Address - Street 1:318 N MADISON ST
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-1911
Practice Address - Country:US
Practice Address - Phone:217-303-8787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190338561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty