Provider Demographics
NPI:1083743777
Name:BENNETT, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 NEWPORT BLVD
Mailing Address - Street 2:#A109-161
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-5031
Mailing Address - Country:US
Mailing Address - Phone:949-548-1976
Mailing Address - Fax:
Practice Address - Street 1:1835 NEWPORT BLVD
Practice Address - Street 2:#A109-161
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-5031
Practice Address - Country:US
Practice Address - Phone:949-548-1976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21238111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC21238OtherCHIROPRACTIC LICENSE