Provider Demographics
NPI:1578237525
Name:NGUYEN, LISA (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:NGUYEN
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 1:1454 DYLAN CHASE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-2712
Mailing Address - Country:US
Mailing Address - Phone:404-769-4788
Mailing Address - Fax:
Practice Address - Street 1:2239 HIGHWAY 20 SE STE H
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2087
Practice Address - Country:US
Practice Address - Phone:770-921-3565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0160921223X0400X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics