Provider Demographics
NPI:1164892311
Name:BENNETT-SELBERT, SONIA (DDS)
Entity Type:Individual
Prefix:
First Name:SONIA
Middle Name:
Last Name:BENNETT-SELBERT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 N 500 E
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-9728
Mailing Address - Country:US
Mailing Address - Phone:317-607-6668
Mailing Address - Fax:
Practice Address - Street 1:2500 ROOSEVELT RD
Practice Address - Street 2:STE B
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383
Practice Address - Country:US
Practice Address - Phone:219-531-9293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012890A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery