Healthcare Provider Details

I. General information

NPI: 1194062703
Provider Name (Legal Business Name): LISA MARIE INGRAM D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA MARIE DUGAN

II. Dates (important events)

Enumeration Date: 01/16/2013
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 E 16TH ST
WELLINGTON KS
67152-2812
US

IV. Provider business mailing address

1015 E 16TH ST
WELLINGTON KS
67152-2812
US

V. Phone/Fax

Practice location:
  • Phone: 620-326-5751
  • Fax: 620-399-8917
Mailing address:
  • Phone: 620-326-5751
  • Fax: 620-399-8917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number61022
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: