Provider Demographics
NPI:1164573879
Name:HERRERA, LISE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISE
Middle Name:
Last Name:HERRERA
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 1:1428 VENTERS DR.
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911
Mailing Address - Country:US
Mailing Address - Phone:619-913-0312
Mailing Address - Fax:619-422-4396
Practice Address - Street 1:1101 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911
Practice Address - Country:US
Practice Address - Phone:619-422-8891
Practice Address - Fax:619-422-4396
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36377122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist