Healthcare Provider Details

I. General information

NPI: 1699154153
Provider Name (Legal Business Name): BENTON FAMILY DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2015
Last Update Date: 02/29/2024
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3299 CLEAR VISTA CT NE, STE A
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

3299 CLEAR VISTA CT NE, STE A
GRAND RAPIDS MI
49525
US

V. Phone/Fax

Practice location:
  • Phone: 616-361-0654
  • Fax: 616-361-9823
Mailing address:
  • Phone: 616-361-0654
  • Fax: 616-361-9823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number014521
License Number StateMI

VIII. Authorized Official

Name: DR. STEPHANIE M BENTON-LANGEJANS
Title or Position: PRESIDENT
Credential: DDS
Phone: 616-361-0654