MEDICARE: BENZLEY PEDIATRIC DENTISTRY, LLC

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	9875	CO

General Provider Information

NPI Number	:	1528398344
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BENZLEY PEDIATRIC DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	753 MALETA LN STE 104
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80108-7605
Country	:	US
Telephone Number	:	303-660-5373
Fax Number	:	303-660-5374

Provider Business Practice Location Address
First Line	:	753 MALETA LN STE 104
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80108-7605
Country	:	US
Telephone Number	:	303-660-5373
Fax Number	:	303-660-5374

Authorized Official
Title or Position	:	PEDIATRIC DENTIST
Name	:	DR. LAYNE P BENZLEY
Credential	:	D.D.S.
Telephone Number	:	303-660-5373

Provider Enumeration Date	:	12/29/2009
Last Update Date	:	12/07/2010

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