Provider Demographics
NPI:1235316217
Name:DR. LISA BAILEY
Entity Type:Organization
Organization Name:DR. LISA BAILEY
Other - Org Name:DR. LISA BAILEY DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:CHURCHMAN
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-644-4976
Mailing Address - Street 1:225 W ASCENSION ST
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-2803
Mailing Address - Country:US
Mailing Address - Phone:225-644-4976
Mailing Address - Fax:225-647-4442
Practice Address - Street 1:225 W ASCENSION ST
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-2803
Practice Address - Country:US
Practice Address - Phone:225-644-4976
Practice Address - Fax:225-647-4442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4685305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1023163599OtherNPPES