Provider Demographics
NPI:1215988050
Name:BENDER, MARISSA N (DMD, MBA)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:N
Last Name:BENDER
Suffix:
Gender:F
Credentials:DMD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4024 116TH ST SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-5371
Mailing Address - Country:US
Mailing Address - Phone:425-316-9268
Mailing Address - Fax:
Practice Address - Street 1:5017 196TH ST SW
Practice Address - Street 2:STE 202
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6123
Practice Address - Country:US
Practice Address - Phone:425-778-5665
Practice Address - Fax:425-778-3356
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000091551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA01606946OtherUNITED CONCORDIA PROVIDER
WA51909OtherDHA/FORTIS PROVIDER ID
WA5582BEOtherREGENCE BLUESHIELD
WA28641OtherWASHINGTON DENTAL SERVICE
WA48726OtherDHA PRACTICE ID
WA5046057Medicaid