Provider Demographics
NPI:1689906323
Name:TAYLOR, LISA (DMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TAYLOR
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 1:42 MARKET SQUARE ROAD
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265
Mailing Address - Country:US
Mailing Address - Phone:770-251-8145
Mailing Address - Fax:770-251-7319
Practice Address - Street 1:42 MARKET SQUARE ROAD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265
Practice Address - Country:US
Practice Address - Phone:770-251-8145
Practice Address - Fax:770-251-7319
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0116971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice