Provider Demographics
NPI:1558401281
Name:BENNETT, MARK ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1331 S ELISEO DR
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2010
Mailing Address - Country:US
Mailing Address - Phone:415-461-1150
Mailing Address - Fax:415-461-1573
Practice Address - Street 1:1331 S ELISEO DR
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2010
Practice Address - Country:US
Practice Address - Phone:415-461-1150
Practice Address - Fax:415-461-1573
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA290161223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology