Provider Demographics
NPI:1750438792
Name:BENNETT, JEFFREY A (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
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 1:5174 WOODWORTH DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOOD PARKDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97041-8737
Mailing Address - Country:US
Mailing Address - Phone:765-438-4228
Mailing Address - Fax:
Practice Address - Street 1:1521 ROCKFORD CT
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3207
Practice Address - Country:US
Practice Address - Phone:765-455-4270
Practice Address - Fax:765-455-4275
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD107791223G0001X
AK1441441223G0001X
IN120099481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200196820Medicaid