MEDICARE: DR. MARK BENAVIDES DDS

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	122300000X	Dentist	19020337	IL

General Provider Information

NPI Number	:	1801233606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK BENAVIDES DDS

Provider Business Mailing Address
First Line	:	1703 POLARIS CIR
Second Line	:	SUITE 3
City	:	OTTAWA
State	:	IL
Zip	:	61350-1683
Country	:	US
Telephone Number	:	815-434-0152
Fax Number	:	815-434-0156

Provider Business Practice Location Address
First Line	:	1703 POLARIS CIR
Second Line	:	SUITE 3
City	:	OTTAWA
State	:	IL
Zip	:	61350-1683
Country	:	US
Telephone Number	:	815-434-0152
Fax Number	:	815-434-0156

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

Provider Enumeration Date	:	06/03/2013
Last Update Date	:	12/17/2013

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