Provider Demographics
NPI:1366615494
Name:INGALDSON, BENJAMIN FRANKLIN (DDS)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:FRANKLIN
Last Name:INGALDSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3380 S KINNICKINNIC AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-3159
Mailing Address - Country:US
Mailing Address - Phone:414-482-2090
Mailing Address - Fax:414-482-0265
Practice Address - Street 1:3380 S KINNICKINNIC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-3159
Practice Address - Country:US
Practice Address - Phone:414-482-2090
Practice Address - Fax:414-482-0265
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001762122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33737000Medicare PIN