Provider Demographics
NPI:1073697306
Name:WENTZ, LISA MCDANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MCDANIEL
Last Name:WENTZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 S LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:RANSOM CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79366-2412
Mailing Address - Country:US
Mailing Address - Phone:806-745-1812
Mailing Address - Fax:
Practice Address - Street 1:4013-84TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423
Practice Address - Country:US
Practice Address - Phone:806-794-8365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX150041223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics