Provider Demographics
NPI:1326380957
Name:REYES, LIZA
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LIZA
Other - Middle Name:
Other - Last Name:REYES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDH
Mailing Address - Street 1:1087 E MARENGO DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-1259
Mailing Address - Country:US
Mailing Address - Phone:956-367-1433
Mailing Address - Fax:
Practice Address - Street 1:92 S GOLFWOOD DR W
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-3673
Practice Address - Country:US
Practice Address - Phone:719-557-0774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-21
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002023485124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist