Provider Demographics
NPI:1174641542
Name:VACULIK, BENNETT J (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:J
Last Name:VACULIK
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 1:903 E LENNON DR STE 108
Mailing Address - Street 2:
Mailing Address - City:EMORY
Mailing Address - State:TX
Mailing Address - Zip Code:75440-5229
Mailing Address - Country:US
Mailing Address - Phone:903-474-6010
Mailing Address - Fax:903-474-6011
Practice Address - Street 1:903 E LENNON DR STE 108
Practice Address - Street 2:
Practice Address - City:EMORY
Practice Address - State:TX
Practice Address - Zip Code:75440-5229
Practice Address - Country:US
Practice Address - Phone:903-474-6010
Practice Address - Fax:903-474-6011
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice