Provider Demographics
NPI:1659500346
Name:MARTIN, LISA LAIRD (DDS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LAIRD
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:LAIRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:220 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:GATESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76528
Mailing Address - Country:US
Mailing Address - Phone:254-865-7272
Mailing Address - Fax:
Practice Address - Street 1:220 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GATESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76528
Practice Address - Country:US
Practice Address - Phone:254-865-7272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice