Healthcare Provider Details

I. General information

NPI: 1164420790
Provider Name (Legal Business Name): LYN A BENTON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 BATH RD
BRUNSWICK ME
04011-2646
US

IV. Provider business mailing address

242 BATH RD
BRUNSWICK ME
04011-2646
US

V. Phone/Fax

Practice location:
  • Phone: 207-729-8474
  • Fax: 207-729-8955
Mailing address:
  • Phone: 207-729-8474
  • Fax: 207-729-8955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number877
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4853
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: