Provider Demographics
NPI:1679703607
Name:BENNETT, KYLE CHARLES
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:CHARLES
Last Name:BENNETT
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 1:12455 E 100TH ST N
Mailing Address - Street 2:SUITE 110
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4674
Mailing Address - Country:US
Mailing Address - Phone:918-274-7100
Mailing Address - Fax:918-274-7128
Practice Address - Street 1:12455 E 100TH ST N
Practice Address - Street 2:SUITE 110
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4674
Practice Address - Country:US
Practice Address - Phone:918-274-7100
Practice Address - Fax:918-274-7128
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2596152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist