Provider Demographics
NPI:1194062703
Name:INGRAM, LISA MARIE (DDS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:DUGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1015 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67152-2812
Mailing Address - Country:US
Mailing Address - Phone:620-326-5751
Mailing Address - Fax:620-399-8917
Practice Address - Street 1:1015 E 16TH ST
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:KS
Practice Address - Zip Code:67152-2812
Practice Address - Country:US
Practice Address - Phone:620-326-5751
Practice Address - Fax:620-399-8917
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS610221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice