MEDICARE: DR. MICHAEL MAURICE BENNETT DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	8046	MN

General Provider Information

NPI Number	:	1942364245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL MAURICE BENNETT DDS

Provider Business Mailing Address
First Line	:	501 N COMMERCIAL AVE
Second Line	:	PO BOX 589
City	:	SANDSTONE
State	:	MN
Zip	:	55072-0589
Country	:	US
Telephone Number	:	320-245-2208
Fax Number	:	320-245-2208

Provider Business Practice Location Address
First Line	:	501 N COMMERCIAL AVE
Second Line	:
City	:	SANDSTONE
State	:	MN
Zip	:	55072-0589
Country	:	US
Telephone Number	:	320-245-2208
Fax Number	:	320-245-2208

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	07/08/2007

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