MEDICARE: DR. TRACY C. BENTON JR. 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	1223G0001X	General Practice Dentistry	3057	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487079208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRACY C. BENTON JR. DDS

Provider Business Mailing Address
First Line	:	PO BOX 952
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70727-0952
Country	:	US
Telephone Number	:	225-664-0040
Fax Number	:	225-664-0042

Provider Business Practice Location Address
First Line	:	1310 S RANGE AVE
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70726-4810
Country	:	US
Telephone Number	:	225-664-0040
Fax Number	:	225-664-0042

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

Provider Enumeration Date	:	03/03/2014
Last Update Date	:	03/03/2014

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