=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043566466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EBBY PRIME, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2012
-----------------------------------------------------
Last Update Date | 08/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 390 N BELL PL
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85225-4200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-568-8116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 652 E WARNER RD STE 101
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85296-3071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-568-8116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. BRETT E BENSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 602-545-8400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------