Provider Demographics
NPI:1639217060
Name:BENNETT, MICHAEL D (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
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 1:3737 N MERIDIAN ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-4348
Mailing Address - Country:US
Mailing Address - Phone:317-931-3229
Mailing Address - Fax:
Practice Address - Street 1:3737 N MERIDIAN ST
Practice Address - Street 2:SUITE 400
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4348
Practice Address - Country:US
Practice Address - Phone:317-931-3229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120077581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100166190Medicaid