Provider Demographics
NPI:1659526143
Name:DANIEL, LISA ANN (RDH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:DANIEL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LAKE TRAVERSE DR
Mailing Address - Street 2:
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262-7046
Mailing Address - Country:US
Mailing Address - Phone:269-615-8425
Mailing Address - Fax:
Practice Address - Street 1:100 LAKE TRAVERSE DR
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262-7046
Practice Address - Country:US
Practice Address - Phone:269-615-8425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402204109124Q00000X
MI2902008683124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist