Healthcare Provider Details

I. General information

NPI: 1326448309
Provider Name (Legal Business Name): DOUGLAS BENTING
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E BETHANY HOME RD STE C194
PHOENIX AZ
85012-1266
US

IV. Provider business mailing address

301 E BETHANY HOME RD STE C194
PHOENIX AZ
85012-1266
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-9088
  • Fax: 602-277-8889
Mailing address:
  • Phone: 602-277-9088
  • Fax: 602-277-8889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberD06755
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: