Provider Demographics
NPI:1558548875
Name:LISA GUSHIN D.D.S. P.A.
Entity Type:Organization
Organization Name:LISA GUSHIN D.D.S. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSHIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-484-1771
Mailing Address - Street 1:203 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3409
Mailing Address - Country:US
Mailing Address - Phone:910-484-1771
Mailing Address - Fax:910-484-8876
Practice Address - Street 1:203 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3409
Practice Address - Country:US
Practice Address - Phone:910-484-1771
Practice Address - Fax:910-484-8876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6908261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899010FMedicaid
NC9010FOtherBCBS
NC586286OtherUNITED CONCORDIA