MEDICARE: DR. THEODORE BENADERET DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	18786	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B18786-01	OTHER	CA	MEDI-CAL (CALIFORNIA)

General Provider Information

NPI Number	:	1124194394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THEODORE BENADERET DDS

Provider Business Mailing Address
First Line	:	9900 MCFADDEN AVE STE 201
Second Line	:
City	:	WESTMINSTER
State	:	CA
Zip	:	92683-6978
Country	:	US
Telephone Number	:	714-531-2513
Fax Number	:	714-531-1603

Provider Business Practice Location Address
First Line	:	9900 MCFADDEN AVE STE 201
Second Line	:
City	:	WESTMINSTER
State	:	CA
Zip	:	92683-6978
Country	:	US
Telephone Number	:	714-531-2513
Fax Number	:	714-531-1603

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	07/08/2007

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