Provider Demographics
NPI:1407221476
Name:BOWMAN, LISA JEANNETTE (RDH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JEANNETTE
Last Name:BOWMAN
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 1:18A MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2111
Mailing Address - Country:US
Mailing Address - Phone:207-671-6587
Mailing Address - Fax:
Practice Address - Street 1:18A MAPLE ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2111
Practice Address - Country:US
Practice Address - Phone:207-671-6587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERDH896124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist