Healthcare Provider Details

I. General information

NPI: 1770575292
Provider Name (Legal Business Name): ANTHONY J BENNETT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 N MCLEAN BLVD SUITE 200
ELGIN IL
60123-5723
US

IV. Provider business mailing address

1425 N MCLEAN BLVD SUITE 200
ELGIN IL
60123-5723
US

V. Phone/Fax

Practice location:
  • Phone: 847-697-6868
  • Fax: 847-697-8355
Mailing address:
  • Phone: 847-697-6868
  • Fax: 847-697-8355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: