Provider Demographics
NPI:1538219043
Name:MANOGIN-BENDER, TERESA (DMD)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:
Last Name:MANOGIN-BENDER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 MANHATTAN RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-6022
Mailing Address - Country:US
Mailing Address - Phone:601-362-0460
Mailing Address - Fax:
Practice Address - Street 1:4550 MANHATTAN RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-6022
Practice Address - Country:US
Practice Address - Phone:601-362-0460
Practice Address - Fax:601-362-1194
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA67231223G0001X
MS283394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660139Medicaid
LA3434661Medicaid