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General NPI Number Information
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NPI Number | 1164046967
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Entity Type | Organization
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Legal Business Name | DR BENNETT LLC
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Dates
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Enumeration Date | 06/08/2020
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Last Update Date | 06/17/2020
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Provider Practice Location Address
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Address Line | 1850 E DUPONT RD
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City | FORT WAYNE
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State | IN
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Zip | 46825-1581
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Country | US
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Telephone | 260-490-1060
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Fax |
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Provider Business Mailing Address
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Address Line | 1850 E DUPONT RD
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City | FORT WAYNE
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State | IN
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Zip | 46825-1581
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Country | US
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Telephone | 260-490-1060
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. LANCE BENNETT
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Credential | OD
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Telephone | 260-417-3467
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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