Provider Demographics
NPI:1063677250
Name:PETERSON, LISA LANZILLOTTI (DMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LANZILLOTTI
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:LANZILLOTTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:116 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILLBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01527-2021
Mailing Address - Country:US
Mailing Address - Phone:508-865-2622
Mailing Address - Fax:
Practice Address - Street 1:116 MAIN ST
Practice Address - Street 2:
Practice Address - City:MILLBURY
Practice Address - State:MA
Practice Address - Zip Code:01527-2021
Practice Address - Country:US
Practice Address - Phone:508-865-2622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10120122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist