Provider Demographics
NPI:1306026372
Name:CIUCCI O'GRADY, LISA ANN (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:CIUCCI O'GRADY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:CIUCCI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1216 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450
Mailing Address - Country:US
Mailing Address - Phone:815-941-4343
Mailing Address - Fax:815-942-8414
Practice Address - Street 1:1216 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450
Practice Address - Country:US
Practice Address - Phone:815-941-4343
Practice Address - Fax:815-942-8414
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-07
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019023659122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist