Provider Demographics
NPI:1164046967
Name:DR BENNETT LLC
Entity Type:Organization
Organization Name:DR BENNETT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-417-3467
Mailing Address - Street 1:1850 E DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1581
Mailing Address - Country:US
Mailing Address - Phone:260-490-1060
Mailing Address - Fax:
Practice Address - Street 1:1850 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1581
Practice Address - Country:US
Practice Address - Phone:260-490-1060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR BENNETT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-08
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
13641379OtherCAQH