Provider Demographics
NPI:1770057184
Name:BENNETT, JARVARIS
Entity type:Individual
Prefix:
First Name:JARVARIS
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2429 3RD AVE SE UNIT A
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-4465
Mailing Address - Country:US
Mailing Address - Phone:678-588-4533
Mailing Address - Fax:
Practice Address - Street 1:209 S 1ST ST
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-1412
Practice Address - Country:US
Practice Address - Phone:320-269-6406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist