Basic Information
| Provider Information | |||||||||
| NPI: | 1013520766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | ROLAND | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | USA DENTAL HEALTH ACTIVITY | ||||||||
| Address2: | 652 HAMILTON ROAD | ||||||||
| City: | FORT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804423905 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | USA DENTAL HEALTH ACTIVITY | ||||||||
| Address2: | 652 HAMILTON ROAD | ||||||||
| City: | FORT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804423905 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2020 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D11299 | OR | Y | Dental Providers | Dentist |
No ID Information.