Provider Demographics
NPI:1508070707
Name:WADSWORTH, LISA ELY (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ELY
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:13940 N US HIGHWAY 441
Mailing Address - Street 2:SUITE 602
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-8908
Mailing Address - Country:US
Mailing Address - Phone:352-750-0008
Mailing Address - Fax:352-259-9145
Practice Address - Street 1:13940 N US HIGHWAY 441
Practice Address - Street 2:SUITE 602
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-8908
Practice Address - Country:US
Practice Address - Phone:352-750-0008
Practice Address - Fax:352-259-9145
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0013864122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist