Provider Demographics
NPI:1598983975
Name:BENNETT, LEE LARUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:LARUE
Last Name:BENNETT
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 1:1221 E CONDIT ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-1405
Mailing Address - Country:US
Mailing Address - Phone:217-423-9930
Mailing Address - Fax:217-233-5787
Practice Address - Street 1:1221 E CONDIT ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-1405
Practice Address - Country:US
Practice Address - Phone:217-423-9930
Practice Address - Fax:217-233-5787
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist