Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 019028101 | IL |
NPI | 1003116617 |
---|---|
Provider Name | Dr. Dale Benjamin |
First Address | Chicago, IL 60612-1304 |
Second Address | Chicago, IL 60639-1108 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/10/2010 |
Last Update Date | 28/10/2010 |