Provider Demographics
NPI:1942347604
Name:BENISH, JACLYN
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:
Last Name:BENISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:BLECHSCHMIDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:311 E TYRANENA PARK RD
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-9681
Mailing Address - Country:US
Mailing Address - Phone:920-648-2331
Mailing Address - Fax:920-648-3437
Practice Address - Street 1:311 E TYRANENA PARK RD
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-9681
Practice Address - Country:US
Practice Address - Phone:920-648-2331
Practice Address - Fax:920-648-3437
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI58251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice