Provider Demographics
NPI:1134646698
Name:BENTON FAMILY DENTISTRY
Entity Type:Organization
Organization Name:BENTON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BETHEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-317-7544
Mailing Address - Street 1:1200 FERGUSON DR STE 4
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-2947
Mailing Address - Country:US
Mailing Address - Phone:501-317-7544
Mailing Address - Fax:
Practice Address - Street 1:1200 FERGUSON DR STE 4
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-2947
Practice Address - Country:US
Practice Address - Phone:501-317-7544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR33391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1861885515Medicaid