Provider Demographics
NPI:1558730804
Name:COOPER, LISA MARIE (RDH,BS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:COOPER
Suffix:
Gender:F
Credentials:RDH,BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 E TEXAS ST
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3603
Mailing Address - Country:US
Mailing Address - Phone:214-435-4501
Mailing Address - Fax:
Practice Address - Street 1:613 E TEXAS ST
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3603
Practice Address - Country:US
Practice Address - Phone:214-435-4501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4457124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist