Provider Demographics
NPI:1619093929
Name:MORRISON, LANITA ANDRE (DMD)
Entity Type:Individual
Prefix:DR
First Name:LANITA
Middle Name:ANDRE
Last Name:MORRISON
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 1:4639 QUIGG DR APT 1233
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-8305
Mailing Address - Country:US
Mailing Address - Phone:480-720-0981
Mailing Address - Fax:
Practice Address - Street 1:1141 PEAR TREE LN
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6484
Practice Address - Country:US
Practice Address - Phone:707-258-6128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD64811223G0001X
FLDN170001223G0001X
CA644581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ156911Medicaid