Provider Demographics
NPI:1598784381
Name:LAX, BENNETT IRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:IRA
Last Name:LAX
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 1/2 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:GREEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12183-1115
Mailing Address - Country:US
Mailing Address - Phone:518-272-2320
Mailing Address - Fax:518-272-2322
Practice Address - Street 1:97 1/2 GEORGE ST
Practice Address - Street 2:
Practice Address - City:GREEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:12183-1115
Practice Address - Country:US
Practice Address - Phone:518-272-2320
Practice Address - Fax:518-272-2322
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031327122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist