Healthcare Provider Details

I. General information

NPI: 1790689362
Provider Name (Legal Business Name): GREGORY BENNETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 STELTON RD
XENIA OH
45385-5220
US

IV. Provider business mailing address

516 BANNOCK ST
DAYTON OH
45404-1502
US

V. Phone/Fax

Practice location:
  • Phone: 937-708-8348
  • Fax:
Mailing address:
  • Phone: 765-488-4238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberPRS.007705
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: