Provider Demographics
NPI:1538293261
Name:BENNETT, JOSEPH RONALD (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:RONALD
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 W WHEELER PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-1899
Mailing Address - Country:US
Mailing Address - Phone:706-210-7061
Mailing Address - Fax:706-210-7065
Practice Address - Street 1:1211 W WHEELER PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1899
Practice Address - Country:US
Practice Address - Phone:706-210-7061
Practice Address - Fax:706-210-7065
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9181916Medicaid
GA560008OtherUNITED CONCORDIA