Provider Demographics
NPI:1740372077
Name:BENNETT, TERRY R (DMD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:R
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 S DENVER AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74119-4233
Mailing Address - Country:US
Mailing Address - Phone:918-582-8651
Mailing Address - Fax:918-583-3903
Practice Address - Street 1:1616 S DENVER AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-4233
Practice Address - Country:US
Practice Address - Phone:918-582-8651
Practice Address - Fax:918-583-3903
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3828122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKT79901Medicare UPIN