=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285194738
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BENDER DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2019
-----------------------------------------------------
Last Update Date | 03/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1345 E FORT UNION BLVD
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84121-2859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-943-3408
-----------------------------------------------------
Fax | 866-611-4680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1713 N 3780 W
-----------------------------------------------------
City | LEHI
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84043-4198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-230-1220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR
-----------------------------------------------------
Name | DR. MATTHEW STEPHEN BENDER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 801-230-1220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------