Provider Demographics
NPI:1467849109
Name:WHITEHEAD, LISA ANN (RDH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:WHITEHEAD
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 1:806 TUURI PL
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2465
Mailing Address - Country:US
Mailing Address - Phone:810-768-7583
Mailing Address - Fax:810-768-7584
Practice Address - Street 1:806 TUURI PL
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2465
Practice Address - Country:US
Practice Address - Phone:810-768-7583
Practice Address - Fax:810-768-7584
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902007792124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist