Provider Demographics
NPI:1295796522
Name:BENNESE, DOMINICK MICHAEL (MBA, ATC/L)
Entity type:Individual
Prefix:MR
First Name:DOMINICK
Middle Name:MICHAEL
Last Name:BENNESE
Suffix:
Gender:M
Credentials:MBA, ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11025 BRISTOL BAY DR
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-7943
Mailing Address - Country:US
Mailing Address - Phone:814-577-1800
Mailing Address - Fax:
Practice Address - Street 1:5500 34TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3506
Practice Address - Country:US
Practice Address - Phone:941-752-2448
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 18482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer