MEDICARE: JOHN A BENUSIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	60424	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	116988	OTHER	KS	BCBS OF KS

General Provider Information

NPI Number	:	1922199603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN A BENUSIS

Provider Business Mailing Address
First Line	:	415 N GRAND AVE
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81003-3111
Country	:	US
Telephone Number	:	719-546-3333
Fax Number	:

Provider Business Practice Location Address
First Line	:	650 N CARRIAGE PKWY
Second Line	:	SUITE #60
City	:	WICHITA
State	:	KS
Zip	:	67208-4507
Country	:	US
Telephone Number	:	316-686-2721
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	07/09/2007

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