Healthcare Provider Details

I. General information

NPI: 1689015299
Provider Name (Legal Business Name): MOLLY BENTHAL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE BLDG 47
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

1501 SAN PEDRO DR SE BLDG 47
ALBUQUERQUE NM
87108-5153
US

V. Phone/Fax

Practice location:
  • Phone: 202-846-3384
  • Fax:
Mailing address:
  • Phone: 202-846-3384
  • Fax: 334-953-8607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0003007
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: