MEDICARE: LISA BENNINGER GILDEA, RDHAP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist

General Provider Information

NPI Number	:	1558117994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISA BENNINGER GILDEA, RDHAP, INC.

Provider Business Mailing Address
First Line	:	4726 SAINT ANDREWS DR
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95219-1915
Country	:	US
Telephone Number	:	209-601-5705
Fax Number	:	209-800-1955

Provider Business Practice Location Address
First Line	:	4726 SAINT ANDREWS DR
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95219-1915
Country	:	US
Telephone Number	:	209-601-5705
Fax Number	:	209-800-1955

Authorized Official
Title or Position	:	CEO
Name	:	LISA GILDEA
Credential	:
Telephone Number	:	209-601-5705

Provider Enumeration Date	:	04/26/2024
Last Update Date	:	05/23/2024

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