Provider Demographics
NPI:1427032424
Name:BENTON, PHILIP LIN (DMD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:LIN
Last Name:BENTON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 E TATUM AVE
Mailing Address - Street 2:
Mailing Address - City:MC COLL
Mailing Address - State:SC
Mailing Address - Zip Code:29570-2323
Mailing Address - Country:US
Mailing Address - Phone:843-523-5291
Mailing Address - Fax:843-523-9714
Practice Address - Street 1:103 E TATUM AVE
Practice Address - Street 2:
Practice Address - City:MC COLL
Practice Address - State:SC
Practice Address - Zip Code:29570-2323
Practice Address - Country:US
Practice Address - Phone:843-523-5291
Practice Address - Fax:843-523-9714
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC2561122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZZ2561Medicaid
SCZA9934Medicaid