Provider Demographics
NPI:1275756660
Name:DAVIS, LEE BENNETT (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:BENNETT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:L.
Other - Middle Name:BENNETT
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:12110 W COUNTY ROAD 550 S
Mailing Address - Street 2:
Mailing Address - City:DALEVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47334-9717
Mailing Address - Country:US
Mailing Address - Phone:765-378-3391
Mailing Address - Fax:765-378-3392
Practice Address - Street 1:12110 W COUNTY ROAD 550 S
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:IN
Practice Address - Zip Code:47334-9717
Practice Address - Country:US
Practice Address - Phone:765-378-3391
Practice Address - Fax:765-378-3392
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007981A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100105830AMedicaid