Provider Demographics
NPI:1245387026
Name:BENNARDO, ANTHONY R (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:R
Last Name:BENNARDO
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 1:1018 S MCLEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-5555
Mailing Address - Country:US
Mailing Address - Phone:847-888-8311
Mailing Address - Fax:847-429-9334
Practice Address - Street 1:1018 S MCLEAN BLVD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-5555
Practice Address - Country:US
Practice Address - Phone:847-888-8311
Practice Address - Fax:847-429-9334
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0221871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice