Healthcare Provider Details

I. General information

NPI: 1912156811
Provider Name (Legal Business Name): KYLE STEPHEN BENNER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 PORTLAND FARMS RD
SCARBOROUGH ME
04074-5301
US

IV. Provider business mailing address

PO BOX 7487
PORTLAND ME
04112-7487
US

V. Phone/Fax

Practice location:
  • Phone: 207-883-2809
  • Fax:
Mailing address:
  • Phone: 207-883-2809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT905
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: