Provider Demographics
NPI:1194877530
Name:BENNETT, JACQUELINE R (DDS)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:R
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 1:2300 N CRAYCROFT RD STE 2
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2808
Mailing Address - Country:US
Mailing Address - Phone:520-886-3303
Mailing Address - Fax:520-886-2236
Practice Address - Street 1:2300 N CRAYCROFT RD STE 2
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2808
Practice Address - Country:US
Practice Address - Phone:520-886-3303
Practice Address - Fax:520-886-2236
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD48911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ524795Medicaid
AZ524795Medicaid
1750326849OtherPRACTICE NPI TYPE 2 NUMBE