Healthcare Provider Details

I. General information

NPI: 1841458841
Provider Name (Legal Business Name): JUSTIN B BENNETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MAIN ST
LEWISTON ME
04240-7027
US

IV. Provider business mailing address

20 TARRATINE DR
BRUNSWICK ME
04011-9515
US

V. Phone/Fax

Practice location:
  • Phone: 207-795-2641
  • Fax: 207-753-7201
Mailing address:
  • Phone: 603-733-6361
  • Fax: 603-733-6361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number018565
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberMD18565
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: