Provider Demographics
NPI:1265530133
Name:BENNION, JOHN WAYNE (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WAYNE
Last Name:BENNION
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 S 32ND ST W
Mailing Address - Street 2:SUITE B
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-6848
Mailing Address - Country:US
Mailing Address - Phone:406-655-0170
Mailing Address - Fax:406-655-2271
Practice Address - Street 1:152 S 32ND ST W
Practice Address - Street 2:SUITE B
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-6848
Practice Address - Country:US
Practice Address - Phone:406-655-0170
Practice Address - Fax:406-655-2271
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT15161223S0112X
MT52461223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0112625Medicaid
MTP00053799OtherRR MEDICARE
MT41004OtherBCBS
MT5512234OtherCHIP
MTD96346Medicare UPIN