Provider Demographics
NPI:1235304197
Name:BENNETT, MICHAEL W (RDH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:BENNETT
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WILLOW CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-7667
Mailing Address - Country:US
Mailing Address - Phone:970-669-2887
Mailing Address - Fax:
Practice Address - Street 1:115 WILLOW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-7667
Practice Address - Country:US
Practice Address - Phone:970-669-2887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO905344124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist