Provider Demographics
NPI:1306204755
Name:RISS, TINA LISA (RDH)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:LISA
Last Name:RISS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3280 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-2827
Mailing Address - Country:US
Mailing Address - Phone:970-663-0278
Mailing Address - Fax:
Practice Address - Street 1:3280 MADISON AVE
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-2827
Practice Address - Country:US
Practice Address - Phone:970-663-0278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-31
Last Update Date:2016-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO000905329124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist