Healthcare Provider Details

I. General information

NPI: 1366946089
Provider Name (Legal Business Name): BENJAMIN KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7007 OLD SAUK RD
MADISON WI
53717-2307
US

IV. Provider business mailing address

7007 OLD SAUK RD
MADISON WI
53717-2307
US

V. Phone/Fax

Practice location:
  • Phone: 608-819-8760
  • Fax:
Mailing address:
  • Phone: 608-819-8760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6002166-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: