Healthcare Provider Details

I. General information

NPI: 1801416722
Provider Name (Legal Business Name): BRANDON K BENNETT DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 N MAPLE ST
ELDON MO
65026-1776
US

IV. Provider business mailing address

202 N MAPLE ST
ELDON MO
65026-1776
US

V. Phone/Fax

Practice location:
  • Phone: 573-392-5213
  • Fax:
Mailing address:
  • Phone: 573-392-5213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. BRANDON KEITH BENNETT
Title or Position: PRESIDENT
Credential: DDS
Phone: 573-392-5213