Provider Demographics
NPI:1215026661
Name:TATUM, LISA JANE (DDS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JANE
Last Name:TATUM
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 1:29 STONERIDGE DRIVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980
Mailing Address - Country:US
Mailing Address - Phone:540-943-0973
Mailing Address - Fax:540-943-0974
Practice Address - Street 1:29 STONERIDGE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980-6598
Practice Address - Country:US
Practice Address - Phone:540-943-0973
Practice Address - Fax:540-943-0974
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007656122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
985885OtherUNITED CONCORDIA
209599OtherANTHEM