Healthcare Provider Details

I. General information

NPI: 1215356092
Provider Name (Legal Business Name): TERRENCE BENNETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 06/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC 07 4040 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

MSC 07 4040 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5551
  • Fax:
Mailing address:
  • Phone:
  • 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 Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number1215356092
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: