Provider Demographics
NPI:1336138684
Name:KING, LISA (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 CARMEL AVE NE
Mailing Address - Street 2:SUITE 403
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-3147
Mailing Address - Country:US
Mailing Address - Phone:505-299-7678
Mailing Address - Fax:505-299-7670
Practice Address - Street 1:8300 CARMEL AVE NE
Practice Address - Street 2:SUITE 403
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-3147
Practice Address - Country:US
Practice Address - Phone:505-299-7678
Practice Address - Fax:505-299-7670
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM17521223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84698Medicaid