Provider Demographics
NPI:1356353429
Name:BENTLEY, JAMES WILLIS JR (DDS)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WILLIS
Last Name:BENTLEY
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 1:14126 SHERMAN WAY
Mailing Address - Street 2:UNIT 3
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-5600
Mailing Address - Country:US
Mailing Address - Phone:818-373-0092
Mailing Address - Fax:
Practice Address - Street 1:14126 SHERMAN WAY
Practice Address - Street 2:UNIT 3
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-5600
Practice Address - Country:US
Practice Address - Phone:818-373-0092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB32025Medicaid