Provider Demographics
NPI:1356453260
Name:CLARK, LISA M (DMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARY
Other - Last Name:BOHNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:BONHAM FAMILY DENTISTRY
Mailing Address - Street 2:101 E 9TH STREET
Mailing Address - City:BONHAM
Mailing Address - State:TX
Mailing Address - Zip Code:75418
Mailing Address - Country:US
Mailing Address - Phone:903-583-8023
Mailing Address - Fax:903-583-1291
Practice Address - Street 1:BONHAM FAMILY DENTISTRY
Practice Address - Street 2:101 E 9TH STREET
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418
Practice Address - Country:US
Practice Address - Phone:903-583-8023
Practice Address - Fax:903-583-1291
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20340122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86D655OtherBC/BC OF TX
86D655Medicare UPIN