Provider Demographics
NPI:1609017490
Name:BENNETT, BRANDON KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:KEITH
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 1:23 MOCKINGBIRD RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-7108
Mailing Address - Country:US
Mailing Address - Phone:314-704-0881
Mailing Address - Fax:573-392-5213
Practice Address - Street 1:202 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:ELDON
Practice Address - State:MO
Practice Address - Zip Code:65026-1776
Practice Address - Country:US
Practice Address - Phone:573-392-5213
Practice Address - Fax:573-392-5213
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090131781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice