MEDICARE: MARK BENAVIDES D.D.S., P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0019-20337	IL

General Provider Information

NPI Number	:	1235201344
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK BENAVIDES D.D.S., P.C.

Provider Business Mailing Address
First Line	:	1703 POLARIS CIR
Second Line	:
City	:	OTTAWA
State	:	IL
Zip	:	61350-1683
Country	:	US
Telephone Number	:	815-434-0152
Fax Number	:

Provider Business Practice Location Address
First Line	:	1703 POLARIS CIR
Second Line	:
City	:	OTTAWA
State	:	IL
Zip	:	61350-1683
Country	:	US
Telephone Number	:	815-434-0152
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARK BENAVIDES
Credential	:	D.D.S.
Telephone Number	:	815-434-0152

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	12/17/2013

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