Provider Demographics
NPI:1275699738
Name:GABRIUS FORTUNATO, LISA
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:GABRIUS FORTUNATO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6218 WASHINGTON AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-3916
Mailing Address - Country:US
Mailing Address - Phone:262-886-1300
Mailing Address - Fax:262-886-1837
Practice Address - Street 1:6218 WASHINGTON AVE
Practice Address - Street 2:SUITE C
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-3916
Practice Address - Country:US
Practice Address - Phone:262-886-1300
Practice Address - Fax:262-886-1837
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice