Provider Demographics
NPI:1427202167
Name:VAHOOMANI, LISA ANN (RDH, BS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:VAHOOMANI
Suffix:
Gender:F
Credentials:RDH, BS
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 13760
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-1760
Mailing Address - Country:US
Mailing Address - Phone:503-409-8731
Mailing Address - Fax:
Practice Address - Street 1:5930 MILL CREEK RD
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:OR
Practice Address - Zip Code:97378-9540
Practice Address - Country:US
Practice Address - Phone:503-409-8731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH2123124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist