Healthcare Provider Details

I. General information

NPI: 1346572252
Provider Name (Legal Business Name): JENNIFER JEAN BENNETT CDA, EFDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 02/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 FAYCREST RD
COLUMBUS OH
43232-5974
US

IV. Provider business mailing address

3301 FAYCREST RD
COLUMBUS OH
43232-5974
US

V. Phone/Fax

Practice location:
  • Phone: 614-321-4332
  • Fax:
Mailing address:
  • Phone: 614-321-4332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number201692
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberEFDA-01263
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: