Provider Demographics
NPI:1164676458
Name:VERSHAY, LISA ANNE (RDH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:VERSHAY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22629 TWAIN HARTE DR
Mailing Address - Street 2:
Mailing Address - City:TWAIN HARTE
Mailing Address - State:CA
Mailing Address - Zip Code:95383-9405
Mailing Address - Country:US
Mailing Address - Phone:209-586-2772
Mailing Address - Fax:
Practice Address - Street 1:22629 TWAIN HARTE DR
Practice Address - Street 2:
Practice Address - City:TWAIN HARTE
Practice Address - State:CA
Practice Address - Zip Code:95383-9405
Practice Address - Country:US
Practice Address - Phone:209-586-2772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDH14683124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist