Provider Demographics
NPI:1053516872
Name:BENNETT, LISA KATHRYN (DDS)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:KATHRYN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:KATHRYN
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-286-4560
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:1860 E EGBERT ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-2475
Practice Address - Country:US
Practice Address - Phone:303-659-4000
Practice Address - Fax:303-659-9306
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00009669122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57478767Medicaid