Healthcare Provider Details

I. General information

NPI: 1326027095
Provider Name (Legal Business Name): ILYA BENJAMIN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 S VALLE VERDE DR SUITE 250
HENDERSON NV
89012-3479
US

IV. Provider business mailing address

55 S VALLE VERDE DR SUITE 250
HENDERSON NV
89012-3479
US

V. Phone/Fax

Practice location:
  • Phone: 702-260-1890
  • Fax: 702-260-7936
Mailing address:
  • Phone: 702-260-1890
  • Fax: 702-260-7936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3724
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: