Provider Demographics
NPI:1689913642
Name:LISSON-SMITH, CARLA A (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:A
Last Name:LISSON-SMITH
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 1:5001 CASSIDY LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-9172
Mailing Address - Country:US
Mailing Address - Phone:813-389-0356
Mailing Address - Fax:
Practice Address - Street 1:2628 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2525
Practice Address - Country:US
Practice Address - Phone:817-468-3077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX335251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice