Provider Demographics
NPI:1588809206
Name:SALLOUM, LISA GABRIELLE (DDS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:GABRIELLE
Last Name:SALLOUM
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 1:9000 GOLFSIDE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7793
Mailing Address - Country:US
Mailing Address - Phone:904-367-1722
Mailing Address - Fax:904-367-1739
Practice Address - Street 1:9000 GOLFSIDE DR
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7793
Practice Address - Country:US
Practice Address - Phone:904-737-8410
Practice Address - Fax:904-367-1739
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN128471223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics