Healthcare Provider Details

I. General information

NPI: 1649534124
Provider Name (Legal Business Name): ANDY BENNION D M D M S P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2012
Last Update Date: 06/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 WILLAMETTE ST STE A
EUGENE OR
97405-2890
US

IV. Provider business mailing address

2233 WILLAMETTE ST STE A
EUGENE OR
97405-2890
US

V. Phone/Fax

Practice location:
  • Phone: 541-687-1151
  • Fax: 541-345-0126
Mailing address:
  • Phone: 541-687-1151
  • Fax: 541-345-0126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD7367
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DAVID ANDERSON BENNION
Title or Position: DOCTOR
Credential: D.M.D.
Phone: 541-687-1151