Healthcare Provider Details

I. General information

NPI: 1023692597
Provider Name (Legal Business Name): BEN JOSEPH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 S KING DR
CHICAGO IL
60616-4108
US

IV. Provider business mailing address

200 N JEFFERSON ST APT 909
CHICAGO IL
60661-1263
US

V. Phone/Fax

Practice location:
  • Phone: 312-313-9777
  • Fax:
Mailing address:
  • Phone: 937-901-1787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.033064
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: