1265715403 NPI number — MRS. MELINDA ELAINE BENTLEY B.S, RDH, LAP

Table of content: MRS. MELINDA ELAINE BENTLEY B.S, RDH, LAP (NPI 1265715403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265715403 NPI number — MRS. MELINDA ELAINE BENTLEY B.S, RDH, LAP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENTLEY
Provider First Name:
MELINDA
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
B.S, RDH, LAP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265715403
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2888 SE TRIANGLE OUTFIT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINEVILLE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97754-2551
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-233-7122
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
257 NE 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINEVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97754-1910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-447-5838
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X , with the licence number:  H4534 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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