Provider Demographics
NPI:1427008705
Name:BENNETT, KRISTIE J (OD)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:J
Last Name:BENNETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:J
Other - Last Name:KUDLAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1056 N HIGHLAND AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3551
Mailing Address - Country:US
Mailing Address - Phone:404-343-0887
Mailing Address - Fax:404-343-2024
Practice Address - Street 1:1056 N HIGHLAND AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-3551
Practice Address - Country:US
Practice Address - Phone:404-343-0887
Practice Address - Fax:404-343-2024
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4510152W00000X
GAOPT002410152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V06671Medicare UPIN
GA1017150001Medicare NSC