Provider Demographics
NPI:1790889251
Name:BENNETT, TRAVIS W (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:W
Last Name:BENNETT
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 1:2914 SW 27TH ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-3841
Mailing Address - Country:US
Mailing Address - Phone:954-600-7981
Mailing Address - Fax:
Practice Address - Street 1:102965 OVERSEAS HWY
Practice Address - Street 2:
Practice Address - City:KEY LARGO
Practice Address - State:FL
Practice Address - Zip Code:33037-4690
Practice Address - Country:US
Practice Address - Phone:305-451-2616
Practice Address - Fax:305-451-4737
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN171221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice