Provider Demographics
NPI:1578865507
Name:LE, LISA K (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:K
Last Name:LE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:805-372-9729
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY 491 S
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:805-372-9729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-24
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD220271223E0200X
TX261011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice