Provider Demographics
NPI:1811165715
Name:BENHAM ORTHODONTICS
Entity type:Organization
Organization Name:BENHAM ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSTIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-350-6500
Mailing Address - Street 1:4060 LEGACY DR STE 303
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-6658
Mailing Address - Country:US
Mailing Address - Phone:214-618-8182
Mailing Address - Fax:214-618-8184
Practice Address - Street 1:4060 LEGACY DR STE 303
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-6658
Practice Address - Country:US
Practice Address - Phone:214-618-8182
Practice Address - Fax:214-618-8184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197672201Medicaid