Provider Demographics
NPI:1134303738
Name:LISK, PHILIP ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ALAN
Last Name:LISK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 PAVERSTONE DR STE A
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-4708
Mailing Address - Country:US
Mailing Address - Phone:919-870-6892
Mailing Address - Fax:919-870-1746
Practice Address - Street 1:901 PAVERSTONE DR STE A
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-4708
Practice Address - Country:US
Practice Address - Phone:919-870-6892
Practice Address - Fax:919-870-1746
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X, 332B00000X
NC67461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990041Medicaid