Healthcare Provider Details

I. General information

NPI: 1578452447
Provider Name (Legal Business Name): BENJAMIN RACINE GILLES DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2025
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

674 BLVD DE FRANCE BUILDING 674
PARRIS ISLAND SC
29905
US

IV. Provider business mailing address

674 BLVD DE FRANCE BUILDING 674
PARRIS ISLAND SC
29905
US

V. Phone/Fax

Practice location:
  • Phone: 312-228-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6001887-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: