Provider Demographics
NPI:1942364245
Name:BENNETT, MICHAEL MAURICE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MAURICE
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N COMMERCIAL AVE
Mailing Address - Street 2:PO BOX 589
Mailing Address - City:SANDSTONE
Mailing Address - State:MN
Mailing Address - Zip Code:55072-0589
Mailing Address - Country:US
Mailing Address - Phone:320-245-2208
Mailing Address - Fax:320-245-2208
Practice Address - Street 1:501 N COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:SANDSTONE
Practice Address - State:MN
Practice Address - Zip Code:55072-0589
Practice Address - Country:US
Practice Address - Phone:320-245-2208
Practice Address - Fax:320-245-2208
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN80461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice