Provider Demographics
NPI:1043566466
Name:EBBY PRIME, LLC
Entity Type:Organization
Organization Name:EBBY PRIME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:E
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-545-8400
Mailing Address - Street 1:652 E WARNER RD
Mailing Address - Street 2:STE 101
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3071
Mailing Address - Country:US
Mailing Address - Phone:602-568-8116
Mailing Address - Fax:
Practice Address - Street 1:390 N BELL PL
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-4200
Practice Address - Country:US
Practice Address - Phone:602-568-8116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty