Provider Demographics
NPI:1932717790
Name:BENNETT, BEN LAWRENCE (DDS)
Entity type:Individual
Prefix:
First Name:BEN
Middle Name:LAWRENCE
Last Name:BENNETT
Suffix:
Gender:M
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:PO BOX 592
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:NE
Mailing Address - Zip Code:69301-0592
Mailing Address - Country:US
Mailing Address - Phone:719-551-0556
Mailing Address - Fax:719-219-1376
Practice Address - Street 1:201 W LAKEWAY RD STE 517
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6343
Practice Address - Country:US
Practice Address - Phone:719-551-0556
Practice Address - Fax:719-219-1376
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD1042122300000X
NE5387122300000X
WY769122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty