Provider Demographics
NPI:1114173077
Name:LISA A BLOCK, DMD, MS, PC
Entity Type:Organization
Organization Name:LISA A BLOCK, DMD, MS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:253-858-8581
Mailing Address - Street 1:3519 56TH ST NW
Mailing Address - Street 2:SUITE 140
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-8593
Mailing Address - Country:US
Mailing Address - Phone:253-858-8581
Mailing Address - Fax:253-858-2189
Practice Address - Street 1:3519 56TH ST NW
Practice Address - Street 2:SUITE 140
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-8593
Practice Address - Country:US
Practice Address - Phone:253-858-8581
Practice Address - Fax:253-858-2189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA68461223G0001X
WA66921223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5013925Medicaid