Provider Demographics
NPI:1689712275
Name:FRIBERG, LISA (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:FRIBERG
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 1:641 NE HIGHWAY 99W
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-2708
Mailing Address - Country:US
Mailing Address - Phone:503-472-9435
Mailing Address - Fax:
Practice Address - Street 1:641 NE HIGHWAY 99W
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-2708
Practice Address - Country:US
Practice Address - Phone:503-472-9435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD77301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice