MEDICARE: DR. GREGORY S BENSON 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	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	36731	WI
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	5803	WI
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	12011706A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982704847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY S BENSON DDS

Provider Business Mailing Address
First Line	:	8809 W 400 N
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-9330
Country	:	US
Telephone Number	:	219-879-8710
Fax Number	:	219-879-8715

Provider Business Practice Location Address
First Line	:	8809 W 400 N
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-9330
Country	:	US
Telephone Number	:	219-879-8710
Fax Number	:	219-879-8715

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

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	09/28/2011

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