Provider Demographics
NPI:1407875149
Name:BENNETT, MARVIN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:R
Last Name:BENNETT
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 1:2619 COLONIAL DR STE B
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-4948
Mailing Address - Country:US
Mailing Address - Phone:406-442-7831
Mailing Address - Fax:406-442-7893
Practice Address - Street 1:2619 COLONIAL DR STE B
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-4948
Practice Address - Country:US
Practice Address - Phone:406-442-7831
Practice Address - Fax:406-442-7893
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT15061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0113256Medicaid
MT5512806OtherCHIPS