Provider Demographics
NPI:1477321339
Name:BOCIO RICHARDSON, SELIN BENJAMIN (DMD)
Entity Type:Individual
Prefix:
First Name:SELIN
Middle Name:BENJAMIN
Last Name:BOCIO RICHARDSON
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 1:808 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2199
Mailing Address - Country:US
Mailing Address - Phone:857-300-9796
Mailing Address - Fax:
Practice Address - Street 1:2424 N 8TH ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-1547
Practice Address - Country:US
Practice Address - Phone:309-382-6404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034728122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist