Provider Demographics
NPI:1508889916
Name:SOSTECKE, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SOSTECKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1363
Mailing Address - Country:US
Mailing Address - Phone:616-866-0164
Mailing Address - Fax:616-866-1804
Practice Address - Street 1:610 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1363
Practice Address - Country:US
Practice Address - Phone:616-866-0164
Practice Address - Fax:616-866-1804
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID118601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice