MEDICARE: DR. GAIL V BENTON D.D.S.

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	1223P0221X	Pediatric Dentistry	3521-09	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3521-09	OTHER	MS	DENTAL LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497747661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GAIL V BENTON D.D.S.

Provider Business Mailing Address
First Line	:	4463 N STATE ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39206
Country	:	US
Telephone Number	:	601-714-2908
Fax Number	:

Provider Business Practice Location Address
First Line	:	4463 N STATE ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39206
Country	:	US
Telephone Number	:	601-714-2908
Fax Number	:

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

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	10/10/2016

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