Provider Demographics
NPI:1184753915
Name:BENNETT, DONALD LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:LEE
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 1:645 N MICHIGAN AVE
Mailing Address - Street 2:550
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2826
Mailing Address - Country:US
Mailing Address - Phone:312-642-5253
Mailing Address - Fax:312-642-5286
Practice Address - Street 1:645 N MICHIGAN AVE
Practice Address - Street 2:550
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2826
Practice Address - Country:US
Practice Address - Phone:312-642-5253
Practice Address - Fax:312-642-5286
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010185421223G0001X
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice