MEDICARE: AB1, PLLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1720744287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AB1, PLLC

Provider Business Mailing Address
First Line	:	104 S OLD BETSY RD
Second Line	:
City	:	KEENE
State	:	TX
Zip	:	76059-2425
Country	:	US
Telephone Number	:	817-641-2272
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 S OLD BETSY RD
Second Line	:
City	:	KEENE
State	:	TX
Zip	:	76059-2425
Country	:	US
Telephone Number	:	817-641-2272
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER/DENTIST
Name	:	BROCK BENNION
Credential	:	DDS
Telephone Number	:	801-227-9234

Provider Enumeration Date	:	11/09/2021
Last Update Date	:	11/09/2021

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