Provider Demographics
NPI:1760509756
Name:BENNION, EDWIN WRIDGE (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:WRIDGE
Last Name:BENNION
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 1:725 GOLF VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9643
Mailing Address - Country:US
Mailing Address - Phone:541-779-7936
Mailing Address - Fax:541-857-1212
Practice Address - Street 1:725 GOLF VIEW DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9643
Practice Address - Country:US
Practice Address - Phone:541-779-7936
Practice Address - Fax:541-857-1212
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD73051223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics