Provider Demographics
NPI:1992234595
Name:BENCK, MOLLY (OD)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:BENCK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-0230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 NORTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2703
Practice Address - Country:US
Practice Address - Phone:920-982-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3455-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist