Provider Demographics
NPI:1679737621
Name:BENTON DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:BENTON DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
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:501-375-3145
Mailing Address - Street 1:425 HWY 5 NORTH
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019
Mailing Address - Country:US
Mailing Address - Phone:501-375-3145
Mailing Address - Fax:
Practice Address - Street 1:425 HWY 5 NORTH
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019
Practice Address - Country:US
Practice Address - Phone:501-375-3145
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR168714631Medicaid