Healthcare Provider Details

I. General information

NPI: 1124462924
Provider Name (Legal Business Name): JEFFREY PAUL BENNETT DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 07/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9115 45TH AVE NE
SEATTLE WA
98115
US

IV. Provider business mailing address

1229 MADISON ST SUITE 1140
SEATTLE WA
98104-3586
US

V. Phone/Fax

Practice location:
  • Phone: 225-573-7414
  • Fax:
Mailing address:
  • Phone: 225-573-7414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6150
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDE60364992
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: