Provider Demographics
NPI:1538655980
Name:GILREATH, LISSA DISPARANO (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISSA
Middle Name:DISPARANO
Last Name:GILREATH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 WOODBURY CIR
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-3758
Mailing Address - Country:US
Mailing Address - Phone:864-404-6958
Mailing Address - Fax:
Practice Address - Street 1:241 STORK WAY
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-1039
Practice Address - Country:US
Practice Address - Phone:864-888-3102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC91731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice