Provider Demographics
NPI:1841218617
Name:BENNETT, GRANT (MD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 CLUB LANE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034
Mailing Address - Country:US
Mailing Address - Phone:501-329-1510
Mailing Address - Fax:501-327-2495
Practice Address - Street 1:550 CLUB LANE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034
Practice Address - Country:US
Practice Address - Phone:501-329-1510
Practice Address - Fax:501-327-2495
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL29147207X00000X
ARE7329207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery