Healthcare Provider Details

I. General information

NPI: 1700235934
Provider Name (Legal Business Name): MATTIE BENNETT D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 ROSS ST
HEFLIN AL
36264-1164
US

IV. Provider business mailing address

6569 LYNN AVE
LEEDS AL
35094-2349
US

V. Phone/Fax

Practice location:
  • Phone: 256-591-3443
  • Fax:
Mailing address:
  • Phone: 256-591-3443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number6305
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: