Provider Demographics
NPI:1740548015
Name:BENSON ORAL SURGERY AND DENTAL IMPLANTS, LLC
Entity type:Organization
Organization Name:BENSON ORAL SURGERY AND DENTAL IMPLANTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:219-879-8710
Mailing Address - Street 1:8809 W 400 N
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-9330
Mailing Address - Country:US
Mailing Address - Phone:219-879-8710
Mailing Address - Fax:
Practice Address - Street 1:8809 W 400 N
Practice Address - Street 2:SUITE 2
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9330
Practice Address - Country:US
Practice Address - Phone:219-879-8710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011706A261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33791200Medicaid
IN201031920AMedicaid
IN201031920AMedicaid