Provider Demographics
NPI:1932156858
Name:BENTLEY, JOSEPH L (OD)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:L
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 296
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37083
Mailing Address - Country:US
Mailing Address - Phone:615-666-6613
Mailing Address - Fax:615-666-8179
Practice Address - Street 1:1051 SCOTTSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:TN
Practice Address - Zip Code:37083
Practice Address - Country:US
Practice Address - Phone:615-666-6613
Practice Address - Fax:615-666-8179
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTOD1237152W00000X
TN5541646152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452031Medicaid
TN1452031Medicaid
TNU12552Medicare UPIN
TN3597651Medicare PIN