MEDICARE: DR. BENNETT IRA LAX D.D.S.

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	122300000X	Dentist	031327	NY

General Provider Information

NPI Number	:	1598784381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BENNETT IRA LAX D.D.S.

Provider Business Mailing Address
First Line	:	97 1/2 GEORGE ST
Second Line	:
City	:	GREEN ISLAND
State	:	NY
Zip	:	12183-1115
Country	:	US
Telephone Number	:	518-272-2320
Fax Number	:	518-272-2322

Provider Business Practice Location Address
First Line	:	97 1/2 GEORGE ST
Second Line	:
City	:	GREEN ISLAND
State	:	NY
Zip	:	12183-1115
Country	:	US
Telephone Number	:	518-272-2320
Fax Number	:	518-272-2322

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	07/08/2007

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