Provider Demographics
NPI:1518028455
Name:AUSTIN, LISA (DMD, MSD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 SE 3RD ST STE A1
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2162
Mailing Address - Country:US
Mailing Address - Phone:541-318-5688
Mailing Address - Fax:
Practice Address - Street 1:1245 SE 3RD ST STE A1
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-2162
Practice Address - Country:US
Practice Address - Phone:541-318-5688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO100791223X0400X
ORD85481223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics