Healthcare Provider Details

I. General information

NPI: 1750915559
Provider Name (Legal Business Name): BENTRY NO. 1, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2517 TIMBER COVE LN
PLANO TX
75093-8832
US

IV. Provider business mailing address

1141 N LOOP 1604 E # 105-612
SAN ANTONIO TX
78232-1339
US

V. Phone/Fax

Practice location:
  • Phone: 972-370-5989
  • Fax:
Mailing address:
  • Phone: 855-598-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JO LEAH MONTGOMERY
Title or Position: MANAGER
Credential:
Phone: 214-454-4542