Basic Information
Provider Information
NPI: 1114390804
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BENDALL
FirstName: AMY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 501 LAPEER AVE
Address2:  
City: SAGINAW
State: MI
PostalCode: 486071203
CountryCode: US
TelephoneNumber: 9897596464
FaxNumber: 9893998233
Practice Location
Address1: 200 N CALEDONIA DR
Address2:  
City: OWOSSO
State: MI
PostalCode: 48867
CountryCode: US
TelephoneNumber: 9897204188
FaxNumber: 9897294849
Other Information
ProviderEnumerationDate: 11/04/2015
LastUpdateDate: 09/27/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
124Q00000X2902014935MIY Dental ProvidersDental Hygienist 

No ID Information.


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