Provider Demographics
NPI:1710095260
Name:RISNER-BAUMAN, ALICIA ANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:ANNE
Last Name:RISNER-BAUMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ALICIA
Other - Middle Name:ANNE
Other - Last Name:RISNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:34 E LAWRENCE RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16929-8801
Mailing Address - Country:US
Mailing Address - Phone:570-827-0145
Mailing Address - Fax:
Practice Address - Street 1:34 E LAWRENCE RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:PA
Practice Address - Zip Code:16929-8801
Practice Address - Country:US
Practice Address - Phone:570-827-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038027122300000X
NY044761-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAV08043Medicare UPIN
V08043Medicare UPIN