Provider Demographics
NPI:1861505364
Name:BENNETT, JILL A (DMD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 E 67TH ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-4943
Mailing Address - Country:US
Mailing Address - Phone:918-493-1865
Mailing Address - Fax:918-492-5831
Practice Address - Street 1:4606 E 67TH ST
Practice Address - Street 2:SUITE 310
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-4943
Practice Address - Country:US
Practice Address - Phone:918-493-1865
Practice Address - Fax:918-492-5831
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5159122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist