=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265671887
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PANTHER HOLLOW DENTAL LODGE, PL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2009
-----------------------------------------------------
Last Update Date | 07/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19240 QUESADA AVE
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33948-3126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-743-7435
-----------------------------------------------------
Fax | 941-743-7429
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19240 QUESADA AVE
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33948-3126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-743-7435
-----------------------------------------------------
Fax | 941-743-7429
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOSEPH C BENDER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 941-743-7435
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------