MEDICARE: DR. JERRY M BENIS D.D.S.

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	13794	OH

General Provider Information

NPI Number	:	1518080720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY M BENIS D.D.S.

Provider Business Mailing Address
First Line	:	6160 STONEWALK LN
Second Line	:
City	:	NEW ALBANY
State	:	OH
Zip	:	43054-7084
Country	:	US
Telephone Number	:	614-939-9611
Fax Number	:

Provider Business Practice Location Address
First Line	:	6465 E BROAD ST
Second Line	:	SUITE C
City	:	COLUMBUS
State	:	OH
Zip	:	43213-1576
Country	:	US
Telephone Number	:	614-868-0808
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	07/08/2007

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