Provider Demographics
NPI:1003968934
Name:LISAGOR, MARK STEVEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEVEN
Last Name:LISAGOR
Suffix:
Gender:M
Credentials:DDS
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Mailing Address - Street 1:477 CALLE HIGUERA
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-1812
Mailing Address - Country:US
Mailing Address - Phone:805-484-3928
Mailing Address - Fax:805-388-1258
Practice Address - Street 1:3687 LAS POSAS RD
Practice Address - Street 2:#180
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-1482
Practice Address - Country:US
Practice Address - Phone:805-484-2705
Practice Address - Fax:805-484-5908
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAD236361223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry