Provider Demographics
NPI:1053416602
Name:BENNETT, JEFFREY DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
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 1:1050 WISHARD BLVD
Mailing Address - Street 2:ROOM 4201
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2872
Mailing Address - Country:US
Mailing Address - Phone:317-278-3699
Mailing Address - Fax:317-278-2243
Practice Address - Street 1:1050 WISHARD BLVD
Practice Address - Street 2:ROOM 4201
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2872
Practice Address - Country:US
Practice Address - Phone:317-278-3699
Practice Address - Fax:317-278-2243
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010608A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200461850AMedicaid
IN200461850AMedicaid