Healthcare Provider Details

I. General information

NPI: 1740548015
Provider Name (Legal Business Name): BENSON ORAL SURGERY AND DENTAL IMPLANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8809 W 400 N SUITE 2
MICHIGAN CITY IN
46360-9330
US

IV. Provider business mailing address

8809 W 400 N SUITE 2
MICHIGAN CITY IN
46360-9330
US

V. Phone/Fax

Practice location:
  • Phone: 219-879-8710
  • Fax:
Mailing address:
  • Phone: 219-879-8710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number12011706A
License Number StateIN

VIII. Authorized Official

Name: GREGORY STEVEN BENSON
Title or Position: OWNER
Credential: DDS
Phone: 219-879-8710