Provider Demographics
NPI:1336553031
Name:MARINE, BENJAMIN M
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:M
Last Name:MARINE
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 1:7017 JOHN DEERE PKWY STE 2B
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8072
Mailing Address - Country:US
Mailing Address - Phone:309-792-0513
Mailing Address - Fax:
Practice Address - Street 1:7017 JOHN DEERE PKWY STE 2B
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265
Practice Address - Country:US
Practice Address - Phone:309-792-0513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.29844122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist