Provider Demographics
NPI:1033660931
Name:BENDER MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:BENDER MEDICAL GROUP, INC
Other - Org Name:MIRAMONT DENTAL HYGIENE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF BUSINESS DEVELOPMENT OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DESAIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-225-5107
Mailing Address - Street 1:4674 SNOW MESA DR
Mailing Address - Street 2:SUITE 140
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-8615
Mailing Address - Country:US
Mailing Address - Phone:970-482-0213
Mailing Address - Fax:970-482-9646
Practice Address - Street 1:313 W DRAKE RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526
Practice Address - Country:US
Practice Address - Phone:970-482-8881
Practice Address - Fax:970-482-9646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH002023867124Q00000X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty