1659587715 NPI number — JAMES BRANDON BENNETT DMD

Table of content: JAMES BRANDON BENNETT DMD (NPI 1659587715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659587715 NPI number — JAMES BRANDON BENNETT DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNETT
Provider First Name:
JAMES
Provider Middle Name:
BRANDON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659587715
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
926 GREAT POND DR STE 2003
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTAMONTE SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32714-7244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-772-5124
Provider Business Mailing Address Fax Number:
407-788-3572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13820 OLD ST AUGUSTINE RD
Provider Second Line Business Practice Location Address:
JACKSONVILLE
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32258-5424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-260-7700
Provider Business Practice Location Address Fax Number:
904-260-7733
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN18368 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: DN013432 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000769100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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