Provider Demographics
NPI:1053814335
Name:BENNETT, BRYCE RYLAN (DDS)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:RYLAN
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 1:13221 W PALO VERDE DR
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-8356
Mailing Address - Country:US
Mailing Address - Phone:804-382-1760
Mailing Address - Fax:
Practice Address - Street 1:2239 N SCHOOL ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819
Practice Address - Country:US
Practice Address - Phone:804-382-1760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2018-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program