Provider Demographics
NPI:1962653121
Name:FISS, BENJAMIN S (DDS)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:S
Last Name:FISS
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 1:919 N MICHIGAN AVE
Mailing Address - Street 2:3RD FL.
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-1681
Mailing Address - Country:US
Mailing Address - Phone:312-951-5230
Mailing Address - Fax:312-951-8839
Practice Address - Street 1:919 N MICHIGAN AVE
Practice Address - Street 2:3RD FL.
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-1681
Practice Address - Country:US
Practice Address - Phone:312-951-5230
Practice Address - Fax:312-951-8839
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1916402122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist