Provider Demographics
NPI:1184614778
Name:BENSON, WILLIAM THADDEUS (DMD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:THADDEUS
Last Name:BENSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:WILLIAM
Other - Middle Name:THADDEUS
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:716 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2656
Mailing Address - Country:US
Mailing Address - Phone:207-221-4747
Mailing Address - Fax:
Practice Address - Street 1:716 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103
Practice Address - Country:US
Practice Address - Phone:978-372-9122
Practice Address - Fax:978-372-6131
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15695122300000X
MEDEN4602122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
X05793OtherBLUE CROSS BLUE SHIELD OF