Provider Demographics
NPI:1770011082
Name:DESIGNER SMILES OF AL, INC.
Entity Type:Organization
Organization Name:DESIGNER SMILES OF AL, INC.
Other - Org Name:JOHN B BENTON JR DDS PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DOCTOR/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:BARRY
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD
Authorized Official - Phone:256-239-5406
Mailing Address - Street 1:90 LARRY GARDNER DR
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-3401
Mailing Address - Country:US
Mailing Address - Phone:256-237-1537
Mailing Address - Fax:
Practice Address - Street 1:90 LARRY GARDNER DR
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-3401
Practice Address - Country:US
Practice Address - Phone:256-237-1537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0006122-C1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty