Healthcare Provider Details

I. General information

NPI: 1013201052
Provider Name (Legal Business Name): TERRY R BENNETT DMD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 S DENVER AVE
TULSA OK
74119-4233
US

IV. Provider business mailing address

1616 S DENVER AVE
TULSA OK
74119-4233
US

V. Phone/Fax

Practice location:
  • Phone: 918-582-8651
  • Fax: 918-582-3903
Mailing address:
  • Phone: 918-582-8651
  • Fax: 918-582-3903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3828
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. TERRY BENNETT
Title or Position: OWNER
Credential: D.M.D.
Phone: 918-582-8651