Provider Demographics
NPI:1003307703
Name:LISA R. GAITHER DMD P.A.
Entity Type:Organization
Organization Name:LISA R. GAITHER DMD P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAITHER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:828-697-2826
Mailing Address - Street 1:1027 HANES MALL BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1310
Mailing Address - Country:US
Mailing Address - Phone:828-697-2826
Mailing Address - Fax:
Practice Address - Street 1:1027 HANES MALL BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1310
Practice Address - Country:US
Practice Address - Phone:828-697-2826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty