Provider Demographics
NPI:1639498595
Name:DEESE, LISA IRISH (DMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:IRISH
Last Name:DEESE
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 1:1100 F AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-1919
Mailing Address - Country:US
Mailing Address - Phone:520-364-3285
Mailing Address - Fax:520-364-4261
Practice Address - Street 1:1100 F AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-1919
Practice Address - Country:US
Practice Address - Phone:520-364-3285
Practice Address - Fax:520-364-3378
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0091221223G0001X
FLDN191001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ192919Medicaid