Provider Demographics
NPI:1457474124
Name:BENNETT, LATHONIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LATHONIA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
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:PO BOX 1010
Mailing Address - Street 2:
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-1010
Mailing Address - Country:US
Mailing Address - Phone:912-996-3303
Mailing Address - Fax:866-379-9998
Practice Address - Street 1:PO BOX 1010
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-1010
Practice Address - Country:US
Practice Address - Phone:843-800-0087
Practice Address - Fax:866-379-9998
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25317122300000X
SC3809122300000X, 1223G0001X, 1223P0221X
GA12503122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry