Provider Demographics
NPI:1205205713
Name:CANNATELLA, LISA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:CANNATELLA
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 1:9301 FIRCREST LN
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-3960
Mailing Address - Country:US
Mailing Address - Phone:925-828-5335
Mailing Address - Fax:925-829-6170
Practice Address - Street 1:9301 FIRCREST LN
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-3960
Practice Address - Country:US
Practice Address - Phone:925-828-5335
Practice Address - Fax:925-829-6170
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41261122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist