Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 018001918 | IL |
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 019032456 | IL |
N | 1223S0112X | Oral and Maxillofacial Surgeon | 10975 | TN |
NPI | 1093172744 |
---|---|
Provider Name | Dr. Benjamin Edward Schaefer |
First Address | Urbana, IL 61801 |
Second Address | Urbana, IL 61801-2529 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/01/2016 |
Last Update Date | 31/07/2020 |