Healthcare Provider Details

I. General information

NPI: 1043473259
Provider Name (Legal Business Name): WAYNE M BENNETT DMD DN5631
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 07/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2421 S MAPLE AVE
SANFORD FL
32771-4269
US

IV. Provider business mailing address

2421 S MAPLE AVE
SANFORD FL
32771-4269
US

V. Phone/Fax

Practice location:
  • Phone: 407-323-5340
  • Fax:
Mailing address:
  • Phone: 407-323-5340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN5631
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: