MEDICARE: CLAXTON FAMILY DENTISTRY LLC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1619539194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLAXTON FAMILY DENTISTRY LLC

Provider Business Mailing Address
First Line	:	1102 N COLUMBIA AVE
Second Line	:
City	:	RINCON
State	:	GA
Zip	:	31326-6807
Country	:	US
Telephone Number	:	912-826-2402
Fax Number	:

Provider Business Practice Location Address
First Line	:	1102 N COLUMBIA AVE
Second Line	:
City	:	RINCON
State	:	GA
Zip	:	31326-6807
Country	:	US
Telephone Number	:	912-826-2402
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ZACKARY L. BENTLEY
Credential	:
Telephone Number	:	912-557-6307

Provider Enumeration Date	:	07/03/2019
Last Update Date	:	07/03/2019

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