Healthcare Provider Details

I. General information

NPI: 1700218674
Provider Name (Legal Business Name): BENJAMIN RYAN GELHAUS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 W BROADWAY AVE
MEDFORD WI
54451
US

IV. Provider business mailing address

1155 W BROADWAY AVE
MEDFORD WI
54451
US

V. Phone/Fax

Practice location:
  • Phone: 715-560-0448
  • Fax:
Mailing address:
  • Phone: 715-560-0448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number476890
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: