Provider Demographics
NPI:1922199603
Name:BENUSIS, JOHN A
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:BENUSIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3111
Mailing Address - Country:US
Mailing Address - Phone:719-546-3333
Mailing Address - Fax:
Practice Address - Street 1:650 N CARRIAGE PKWY
Practice Address - Street 2:SUITE #60
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-4507
Practice Address - Country:US
Practice Address - Phone:316-686-2721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS604241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS116988OtherBCBS OF KS