Provider Demographics
NPI:1730497249
Name:GORTARI, LISA MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:GORTARI
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 1:3301 N K CTR
Mailing Address - Street 2:D206
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-1528
Mailing Address - Country:US
Mailing Address - Phone:909-229-3134
Mailing Address - Fax:
Practice Address - Street 1:800 E DOVE AVE
Practice Address - Street 2:STE C
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-2262
Practice Address - Country:US
Practice Address - Phone:909-229-3134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-17
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59423122300000X, 1223D0004X
TX27675122300000X, 1223D0004X
AZD008600122300000X, 1223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDentist Anesthesiologist
No122300000XDental ProvidersDentist