MEDICARE: BENDER MEDICAL GROUP, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1619421351
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BENDER MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	4674 SNOW MESA DR STE 140
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80528-8614
Country	:	US
Telephone Number	:	970-225-5107
Fax Number	:

Provider Business Practice Location Address
First Line	:	313 W DRAKE RD
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-2846
Country	:	US
Telephone Number	:	970-482-8881
Fax Number	:	970-482-9646

Authorized Official
Title or Position	:	CHIEF BUSINESS DEVELOPMENT OFFICER
Name	:	JULIE M DESAIRE
Credential	:
Telephone Number	:	970-225-5107

Provider Enumeration Date	:	08/11/2016
Last Update Date	:	08/11/2016

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