Provider Demographics
NPI:1578659967
Name:MARIN, LISA G (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:G
Last Name:MARIN
Suffix:
Gender:F
Credentials:DMD, MD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:G
Other - Last Name:HUDDLESTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0001
Mailing Address - Country:US
Mailing Address - Phone:706-721-9744
Mailing Address - Fax:706-721-6778
Practice Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0001
Practice Address - Country:US
Practice Address - Phone:706-721-9744
Practice Address - Fax:706-721-6778
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0468761223S0112X
GADN0108981223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02530936Medicaid