Provider Demographics
NPI:1376175265
Name:GILDEA, LISA (RDHAP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GILDEA
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4726 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-1915
Mailing Address - Country:US
Mailing Address - Phone:209-601-5705
Mailing Address - Fax:
Practice Address - Street 1:701 E CHANNEL ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2628
Practice Address - Country:US
Practice Address - Phone:209-601-5705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP748124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist