Provider Demographics
NPI:1417078023
Name:HALL, LISA D (DMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:HALL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:
Mailing Address - City:BEATTYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41311-0690
Mailing Address - Country:US
Mailing Address - Phone:606-464-0151
Mailing Address - Fax:606-464-0151
Practice Address - Street 1:60 CENTER ST
Practice Address - Street 2:
Practice Address - City:BEATTYVILLE
Practice Address - State:KY
Practice Address - Zip Code:41311-9085
Practice Address - Country:US
Practice Address - Phone:606-464-9262
Practice Address - Fax:066-208-8122
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6568122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6568OtherKY LICENSE KENTUCKY DENTA
KY60065687Medicaid
KY31000862OtherMEDICAID FQHC