Provider Demographics
NPI:1144459587
Name:BENTJEN, KIMBERLY C (DDS, MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:C
Last Name:BENTJEN
Suffix:
Gender:F
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10455 DOUBLE R BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-9038
Mailing Address - Country:US
Mailing Address - Phone:775-284-2500
Mailing Address - Fax:
Practice Address - Street 1:10455 DOUBLE R BLVD STE 101
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-9038
Practice Address - Country:US
Practice Address - Phone:775-284-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS2-164C1223S0112X
PADS0402391223S0112X
MN56487204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN850000135Medicare PIN