Provider Demographics
NPI:1093036709
Name:LAKE SAMMAMISH FAMILY DENTISTRY
Entity Type:Organization
Organization Name:LAKE SAMMAMISH FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LISIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-392-3900
Mailing Address - Street 1:5712 E LAKE SAMMAMISH PKWY SE
Mailing Address - Street 2:STE 108
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-8943
Mailing Address - Country:US
Mailing Address - Phone:425-392-3900
Mailing Address - Fax:
Practice Address - Street 1:5712 E LAKE SAMMAMISH PKWY SE
Practice Address - Street 2:STE 108
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-8943
Practice Address - Country:US
Practice Address - Phone:425-392-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600653611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty