1821319476 NPI number — BENTON FAMILY DENTISTRY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821319476 NPI number — BENTON FAMILY DENTISTRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENTON FAMILY DENTISTRY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1821319476
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 427
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71006-0427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-965-2424
Provider Business Mailing Address Fax Number:
318-965-0943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
192 BURT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71006-4900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-965-2424
Provider Business Practice Location Address Fax Number:
318-965-0943
Provider Enumeration Date:
06/17/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CRUMP
Authorized Official First Name:
MISTY
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
318-965-2424

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5793 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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