1366891038 NPI number — MRS. SHELBIE NICOLE BENTON RDH

Table of content: MRS. SHELBIE NICOLE BENTON RDH (NPI 1366891038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366891038 NPI number — MRS. SHELBIE NICOLE BENTON RDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENTON
Provider First Name:
SHELBIE
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RDH
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:
1366891038
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4323 HILL ST.
Provider Second Line Business Mailing Address:
USA DENTAC-
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4323 HILL ST.
Provider Second Line Business Practice Location Address:
USA DENTAC-
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-751-6209
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/03/2016

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:  3860 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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