Provider Demographics
NPI:1164420790
Name:BENTON, LYN A (OD)
Entity Type:Individual
Prefix:
First Name:LYN
Middle Name:A
Last Name:BENTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 BATH RD
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2646
Mailing Address - Country:US
Mailing Address - Phone:207-729-8474
Mailing Address - Fax:207-729-8955
Practice Address - Street 1:242 BATH RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2646
Practice Address - Country:US
Practice Address - Phone:207-729-8474
Practice Address - Fax:207-729-8955
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME877152W00000X
MA4853152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME061177OtherANTHEM BCBS
ME418030099Medicaid
MEAA20124OtherHARVARD PILGRIM
ME7717974OtherCIGNA HEALTHCARE
ME0699960003Medicare NSC
MEAA20124OtherHARVARD PILGRIM