Provider Demographics
NPI:1386087500
Name:BENNETT, WILLIAM (DMD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
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 1:317 REDMOND RD NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1539
Mailing Address - Country:US
Mailing Address - Phone:706-291-2901
Mailing Address - Fax:706-291-7023
Practice Address - Street 1:317 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1539
Practice Address - Country:US
Practice Address - Phone:706-291-2901
Practice Address - Fax:706-291-7023
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA141051223X0400X
GA20020183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No183500000XPharmacy Service ProvidersPharmacist