Provider Demographics
NPI:1073853263
Name:HAYNES, LISSADE & ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:HAYNES, LISSADE & ASSOCIATES, PLLC
Other - Org Name:LONG CREEK FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:LISSADE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-202-3230
Mailing Address - Street 1:8150 MOUNT HOLLY HUNTERSVILLE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-9791
Mailing Address - Country:US
Mailing Address - Phone:610-202-3230
Mailing Address - Fax:
Practice Address - Street 1:8150 MOUNT HOLLY HUNTERSVILLE RD
Practice Address - Street 2:SUITE A
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-9791
Practice Address - Country:US
Practice Address - Phone:610-202-3230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-25
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental