Provider Demographics
NPI:1164097770
Name:RICHARDSON, BENJAMIN QUENZER (DMD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:QUENZER
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 W NORTH AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1335
Mailing Address - Country:US
Mailing Address - Phone:812-550-4391
Mailing Address - Fax:
Practice Address - Street 1:95 S WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5204
Practice Address - Country:US
Practice Address - Phone:224-515-7390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2025-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0356501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice