Provider Demographics
NPI:1275635617
Name:BENNOT, ROBERT K
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:K
Last Name:BENNOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-0509
Mailing Address - Country:US
Mailing Address - Phone:920-787-3200
Mailing Address - Fax:920-787-2541
Practice Address - Street 1:N2888 STATE ROAD 22
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-5265
Practice Address - Country:US
Practice Address - Phone:920-787-3200
Practice Address - Fax:920-787-2541
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5231-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice