Provider Demographics
NPI:1497067722
Name:MCKINLEY, BENJAMIN ANDREW (DDS)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ANDREW
Last Name:MCKINLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-4117
Mailing Address - Country:US
Mailing Address - Phone:715-483-3221
Mailing Address - Fax:715-483-0507
Practice Address - Street 1:26425 LAKELAND AVE S
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:WI
Practice Address - Zip Code:54893-8343
Practice Address - Country:US
Practice Address - Phone:715-866-4420
Practice Address - Fax:715-866-4368
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12788122300000X
WI10020541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZVAD000Medicare UPIN