Provider Demographics
NPI:1154392769
Name:BENTLEY, THERESA HANH DANG
Entity type:Individual
Prefix:
First Name:THERESA HANH
Middle Name:DANG
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESA HANH
Other - Middle Name:
Other - Last Name:DANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:4015 N FRESNO ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-4023
Mailing Address - Country:US
Mailing Address - Phone:559-224-4860
Mailing Address - Fax:559-224-0802
Practice Address - Street 1:4015 N FRESNO ST
Practice Address - Street 2:SUITE 110
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-4023
Practice Address - Country:US
Practice Address - Phone:559-224-4860
Practice Address - Fax:559-224-0802
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD320541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB32054-01Medicaid