Provider Demographics
NPI:1295720910
Name:BENTZ, MARY ANN DIONNE
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:DIONNE
Last Name:BENTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 HARTFORD TPKE STE 103
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-4276
Mailing Address - Country:US
Mailing Address - Phone:860-442-1346
Mailing Address - Fax:860-444-6208
Practice Address - Street 1:914 HARTFORD TPKE STE 103
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-4276
Practice Address - Country:US
Practice Address - Phone:860-442-1346
Practice Address - Fax:860-444-6208
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035094207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2495463OtherUNITED HEALTH CARE
P380349OtherOXFORD
CT4090841Medicaid
030840OtherHEALTH NET
CT001350941Medicaid
010035094CT01OtherANTHEM BLUE SHIELD
CT4090841Medicaid
2495463OtherUNITED HEALTH CARE
030840OtherHEALTH NET
070013830Medicare ID - Type UnspecifiedRAILROAD