Provider Demographics
NPI:1457474082
Name:MUSGRAVE, LISA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:MUSGRAVE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 S BENZIE BLVD
Mailing Address - Street 2:P.O. BOX 378
Mailing Address - City:BEULAH
Mailing Address - State:MI
Mailing Address - Zip Code:49617-8546
Mailing Address - Country:US
Mailing Address - Phone:231-882-9683
Mailing Address - Fax:231-882-5192
Practice Address - Street 1:124 S BENZIE BLVD
Practice Address - Street 2:
Practice Address - City:BEULAH
Practice Address - State:MI
Practice Address - Zip Code:49617-8546
Practice Address - Country:US
Practice Address - Phone:231-882-9683
Practice Address - Fax:231-882-5192
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010441A122300000X
MI2901021135122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist