Provider Demographics
NPI:1679636419
Name:BENNETT, JERRY DELL JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:DELL
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 UNIVERSITY DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2626
Mailing Address - Country:US
Mailing Address - Phone:229-671-1900
Mailing Address - Fax:229-671-1999
Practice Address - Street 1:305 UNIVERSITY DR
Practice Address - Street 2:SUITE 3
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2626
Practice Address - Country:US
Practice Address - Phone:229-671-1900
Practice Address - Fax:229-671-1999
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11534122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1427670OtherUNITED CONCORDIA
GA9813258OtherDORAL
GA100967OtherAVESIS