Provider Demographics
NPI:1982704847
Name:BENSON, GREGORY S (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:S
Last Name:BENSON
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 1:8809 W 400 N
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-9330
Mailing Address - Country:US
Mailing Address - Phone:219-879-8710
Mailing Address - Fax:219-879-8715
Practice Address - Street 1:8809 W 400 N
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9330
Practice Address - Country:US
Practice Address - Phone:219-879-8710
Practice Address - Fax:219-879-8715
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36731204E00000X
WI58031223S0112X
IN12011706A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33791200Medicaid
WI001377750Medicare ID - Type Unspecified
WI33791200Medicaid