Basic Information
| Provider Information | |||||||||
| NPI: | 1215958053 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | DEAN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 71230 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191766230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033836424 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13350 FRANKLIN FARM ROAD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | HERNDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 20171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034715300 | ||||||||
| FaxNumber: | 7034714391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 03/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 0101036600 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200019375 | 01 | MEDICARE RAILROAD | OTHER | 6402062 | 05 | VA | MEDICAID |