Healthcare Provider Details

I. General information

NPI: 1679107023
Provider Name (Legal Business Name): DILLON JOEL BENNETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1822 S 4TH ST
AMES IA
50011-1142
US

IV. Provider business mailing address

4820 MORTENSEN RD UNIT 308
AMES IA
50014-5532
US

V. Phone/Fax

Practice location:
  • Phone: 515-294-6721
  • Fax:
Mailing address:
  • Phone: 641-278-0250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: