Provider Demographics
NPI:1821319476
Name:BENTON FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:BENTON FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUMP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-965-2424
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-0427
Mailing Address - Country:US
Mailing Address - Phone:318-965-2424
Mailing Address - Fax:318-965-0943
Practice Address - Street 1:192 BURT BLVD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:LA
Practice Address - Zip Code:71006-4900
Practice Address - Country:US
Practice Address - Phone:318-965-2424
Practice Address - Fax:318-965-0943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA57931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty