Provider Demographics
NPI:1417108366
Name:BENNETT & MAXWELL FAMILY DENTISTRY
Entity type:Organization
Organization Name:BENNETT & MAXWELL FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:COURTNEY
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:229-671-1900
Mailing Address - Street 1:2415 ANDOVER DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1280
Mailing Address - Country:US
Mailing Address - Phone:229-671-1900
Mailing Address - Fax:229-671-1999
Practice Address - Street 1:2415 ANDOVER DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1280
Practice Address - Country:US
Practice Address - Phone:229-671-1900
Practice Address - Fax:229-671-1999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11562122300000X
GA11534122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000961276AMedicaid
GA000963256AMedicaid