Healthcare Provider Details

I. General information

NPI: 1982220992
Provider Name (Legal Business Name): CHRISTIAN MICHAEL BENNETT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W MAIN ST
VINE GROVE KY
40175-1304
US

IV. Provider business mailing address

822 N ELM ST
HENDERSON KY
42420-2709
US

V. Phone/Fax

Practice location:
  • Phone: 270-877-2011
  • Fax: 270-877-8553
Mailing address:
  • Phone: 270-826-8899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10516
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: