Provider Demographics
NPI:1174828495
Name:BLAIR, LISA (RDH)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:BLAIR
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 1:343 WELLSIAN WAY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-4107
Mailing Address - Country:US
Mailing Address - Phone:509-967-5344
Mailing Address - Fax:509-943-9020
Practice Address - Street 1:343 WELLSIAN WAY
Practice Address - Street 2:SUITE 103
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4107
Practice Address - Country:US
Practice Address - Phone:509-967-5344
Practice Address - Fax:509-943-9020
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5965124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist