Provider Demographics
NPI:1801233606
Name:BENAVIDES, MARK (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:BENAVIDES
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 1:1703 POLARIS CIR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-1683
Mailing Address - Country:US
Mailing Address - Phone:815-434-0152
Mailing Address - Fax:815-434-0156
Practice Address - Street 1:1703 POLARIS CIR
Practice Address - Street 2:SUITE 3
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-1683
Practice Address - Country:US
Practice Address - Phone:815-434-0152
Practice Address - Fax:815-434-0156
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19020337122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist