Provider Demographics
NPI:1003099839
Name:BENDER DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:BENDER DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:MANOGIN
Authorized Official - Last Name:BENDER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-362-0460
Mailing Address - Street 1:4550 MANHATTAN RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-6022
Mailing Address - Country:US
Mailing Address - Phone:601-362-0460
Mailing Address - Fax:
Practice Address - Street 1:4550 MANHATTAN RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-6022
Practice Address - Country:US
Practice Address - Phone:601-362-0460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENDER DENTAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-15
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2833-941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01528564Medicaid