Provider Demographics
NPI:1235704503
Name:MASSEY, LISA ALLEN (RDA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ALLEN
Last Name:MASSEY
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 RENAISSANCE PKWY STE 240
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-2418
Mailing Address - Country:US
Mailing Address - Phone:714-942-4161
Mailing Address - Fax:
Practice Address - Street 1:1205 RENAISSANCE PKWY STE 240
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-2418
Practice Address - Country:US
Practice Address - Phone:714-942-4161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73043126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA73043OtherREGISTERED DENTAL ASSISTANT