Provider Demographics
NPI:1407968803
Name:BENNETT, MAC LEON III (DDS)
Entity Type:Individual
Prefix:MR
First Name:MAC
Middle Name:LEON
Last Name:BENNETT
Suffix:III
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:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77864
Mailing Address - Country:US
Mailing Address - Phone:936-348-5158
Mailing Address - Fax:936-348-5622
Practice Address - Street 1:714 B SOUTH MADISON
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TX
Practice Address - Zip Code:77864
Practice Address - Country:US
Practice Address - Phone:936-348-5158
Practice Address - Fax:936-348-5622
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG6025601OtherTEXAS CHIP
TX008028501Medicaid
TX86D579OtherBLUE CROSS BLUE SHIELD