Provider Demographics
NPI:1235205527
Name:BLACKMON, LISA DENISE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:DENISE
Last Name:BLACKMON
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 1:3729 LEE ROAD
Mailing Address - Street 2:SHAKER HEIGHTS DENTAL EXPRESS
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44120
Mailing Address - Country:US
Mailing Address - Phone:216-751-9922
Mailing Address - Fax:216-752-0870
Practice Address - Street 1:3729 LEE ROAD
Practice Address - Street 2:SHAKER HEIGHTS DENTAL EXPRESS
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44120
Practice Address - Country:US
Practice Address - Phone:216-751-9922
Practice Address - Fax:216-752-0870
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20813122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2066580Medicaid