Provider Demographics
NPI:1699841908
Name:RUNCK, LISA ANNE (DDS MS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:RUNCK
Suffix:
Gender:F
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-3501
Mailing Address - Country:US
Mailing Address - Phone:507-388-2989
Mailing Address - Fax:507-388-2985
Practice Address - Street 1:120 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3501
Practice Address - Country:US
Practice Address - Phone:507-388-2989
Practice Address - Fax:507-388-2985
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112891223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics