Provider Demographics
NPI:1174829501
Name:BENNETT, KINYATTA (DMD)
Entity Type:Individual
Prefix:DR
First Name:KINYATTA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:KINYATTA
Other - Middle Name:
Other - Last Name:MAGEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:13179 THREE RIVERS RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4944
Mailing Address - Country:US
Mailing Address - Phone:228-832-1000
Mailing Address - Fax:
Practice Address - Street 1:13179 THREE RIVERS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4944
Practice Address - Country:US
Practice Address - Phone:228-832-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3564101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice