Healthcare Provider Details

I. General information

NPI: 1932157609
Provider Name (Legal Business Name): SANDRA J. BENNETT DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22400 SE STARK ST
GRESHAM OR
97030-2656
US

IV. Provider business mailing address

22400 SE STARK ST
GRESHAM OR
97030-2656
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-0438
  • Fax: 503-665-4870
Mailing address:
  • Phone: 503-667-0438
  • Fax: 503-665-4870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD7351
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: