Provider Demographics
NPI:1730674664
Name:BENNETT, CHRISTINA MAE (DMD)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MAE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 SAEMANN AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-2342
Mailing Address - Country:US
Mailing Address - Phone:415-847-3995
Mailing Address - Fax:
Practice Address - Street 1:1721 SAEMANN AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081
Practice Address - Country:US
Practice Address - Phone:920-783-6633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-23
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001867-15122300000X
WI10018671223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No122300000XDental ProvidersDentist