Healthcare Provider Details

I. General information

NPI: 1457463820
Provider Name (Legal Business Name): MAC L BENNETT III DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 B SOUTH MADISON
MADISONVILLE TX
77864
US

IV. Provider business mailing address

PO BOX 100
MADISONVILLE TX
77864
US

V. Phone/Fax

Practice location:
  • Phone: 936-348-5158
  • Fax: 936-348-5622
Mailing address:
  • Phone: 936-348-5158
  • Fax: 936-348-5622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MR. MAC LEON BENNETT III
Title or Position: PRESIDENT
Credential: DDS
Phone: 936-348-5158