Healthcare Provider Details

I. General information

NPI: 1538207519
Provider Name (Legal Business Name): KENNETH BENUSIS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 COLUMBUS ST
RAPID CITY SD
57701-3541
US

IV. Provider business mailing address

812 COLUMBUS ST
RAPID CITY SD
57701-3541
US

V. Phone/Fax

Practice location:
  • Phone: 605-341-5431
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberM520
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: