Provider Demographics
NPI:1366581886
Name:DR TRACY C BENTON DDS APDC
Entity type:Organization
Organization Name:DR TRACY C BENTON DDS APDC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-664-0040
Mailing Address - Street 1:PO BOX 952
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70727-0952
Mailing Address - Country:US
Mailing Address - Phone:225-664-0040
Mailing Address - Fax:
Practice Address - Street 1:1310 SOUTH RANGE AVE
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726
Practice Address - Country:US
Practice Address - Phone:225-664-0040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA30571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1830577Medicaid