Provider Demographics
NPI:1063828374
Name:RIVERBEND FAMILY DENTAL
Entity Type:Organization
Organization Name:RIVERBEND FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:BENWARE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:607-722-6985
Mailing Address - Street 1:260 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2745
Mailing Address - Country:US
Mailing Address - Phone:607-722-6985
Mailing Address - Fax:607-723-7083
Practice Address - Street 1:260 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2745
Practice Address - Country:US
Practice Address - Phone:607-722-6985
Practice Address - Fax:607-723-7083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========2Medicaid