Provider Demographics
NPI:1487079208
Name:BENTON, TRACY C JR (DDS)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:C
Last Name:BENTON
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:225-664-0042
Practice Address - Street 1:1310 S RANGE AVE
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-4810
Practice Address - Country:US
Practice Address - Phone:225-664-0040
Practice Address - Fax:225-664-0042
Is Sole Proprietor?:No
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA30571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1830577Medicaid