Provider Demographics
NPI:1699826966
Name:BENTON, NARDOS A (DMD)
Entity Type:Individual
Prefix:DR
First Name:NARDOS
Middle Name:A
Last Name:BENTON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 FIVE FORKS TRICKUM RD SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-1810
Mailing Address - Country:US
Mailing Address - Phone:859-420-6571
Mailing Address - Fax:
Practice Address - Street 1:3050 FIVE FORKS TRICKUM RD SW STE H
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-1877
Practice Address - Country:US
Practice Address - Phone:859-420-6571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY77561223G0001X
GADN0146971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice