Provider Demographics
NPI:1679766638
Name:BAINES, LISA MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:BAINES
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 1:1905 MONTANA DR
Mailing Address - Street 2:SUITE 30
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7008
Mailing Address - Country:US
Mailing Address - Phone:217-698-9300
Mailing Address - Fax:217-698-9310
Practice Address - Street 1:1905 MONTANA DR
Practice Address - Street 2:SUITE 30
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7008
Practice Address - Country:US
Practice Address - Phone:217-698-9300
Practice Address - Fax:217-698-9310
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0274071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice