Provider Demographics
NPI:1528417797
Name:PYUN, LISA (DDS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PYUN
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 1:10203 TANAGER LN STE 101
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-4171
Mailing Address - Country:US
Mailing Address - Phone:443-896-0002
Mailing Address - Fax:443-896-0012
Practice Address - Street 1:10203 TANAGER LN STE 101
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-4171
Practice Address - Country:US
Practice Address - Phone:443-896-0002
Practice Address - Fax:443-896-0012
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16082122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty