Provider Demographics
NPI:1609948462
Name:BENSON, CHARLES DEON
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DEON
Last Name:BENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:H
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:148 VINCENT ST
Mailing Address - Street 2:P O 370
Mailing Address - City:SMITHS GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:42171
Mailing Address - Country:US
Mailing Address - Phone:270-563-4706
Mailing Address - Fax:270-563-4819
Practice Address - Street 1:148 VINCENT STREET
Practice Address - Street 2:P O 370
Practice Address - City:SMITHS GROVE
Practice Address - State:KY
Practice Address - Zip Code:42171
Practice Address - Country:US
Practice Address - Phone:270-563-4706
Practice Address - Fax:270-563-4819
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48491223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist