Provider Demographics
NPI:1811342595
Name:SMITH, BENNETT
Entity type:Individual
Prefix:
First Name:BENNETT
Middle Name:
Last Name:SMITH
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 1:99 POND AVE APT 521
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7117
Mailing Address - Country:US
Mailing Address - Phone:248-505-8591
Mailing Address - Fax:
Practice Address - Street 1:495 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-1007
Practice Address - Country:US
Practice Address - Phone:617-783-0500
Practice Address - Fax:617-783-5514
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA168177208000000X
390200000X
MA292464208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program