Provider Demographics
NPI:1780033795
Name:BENEDICT, TRISTAN SCOTT
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:SCOTT
Last Name:BENEDICT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 S 460 W
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:UT
Mailing Address - Zip Code:84737-2177
Mailing Address - Country:US
Mailing Address - Phone:435-218-4927
Mailing Address - Fax:
Practice Address - Street 1:474 W 200 N
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-4505
Practice Address - Country:US
Practice Address - Phone:435-634-5600
Practice Address - Fax:435-986-8700
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT197272669247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other