Provider Demographics
NPI:1689749434
Name:MENEFEE, LISA K (DDS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:K
Last Name:MENEFEE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1150
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1150
Mailing Address - Country:US
Mailing Address - Phone:812-323-9970
Mailing Address - Fax:812-323-9961
Practice Address - Street 1:420 N WEST ST
Practice Address - Street 2:
Practice Address - City:ODON
Practice Address - State:IN
Practice Address - Zip Code:47562-1036
Practice Address - Country:US
Practice Address - Phone:812-323-9970
Practice Address - Fax:812-323-9961
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120105911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200459180Medicaid