Provider Demographics
NPI:1043566706
Name:BENNETT, CHASE ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHASE
Middle Name:ALAN
Last Name:BENNETT
Suffix:
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 1:9474 KEARNY VILLA RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4595
Mailing Address - Country:US
Mailing Address - Phone:619-494-5091
Mailing Address - Fax:619-881-0408
Practice Address - Street 1:9474 KEARNY VILLA RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4595
Practice Address - Country:US
Practice Address - Phone:619-494-5091
Practice Address - Fax:619-881-0408
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61279122300000X, 174400000X
CO202272122300000X, 174400000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No122300000XDental ProvidersDentist
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment