Provider Demographics
NPI:1750857017
Name:GREENE, LISA MARIE (RDH)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:GREENE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:578 SUTTON WAY
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5390
Mailing Address - Country:US
Mailing Address - Phone:530-277-6193
Mailing Address - Fax:
Practice Address - Street 1:15301 TYLER FOOTE RD
Practice Address - Street 2:
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-9318
Practice Address - Country:US
Practice Address - Phone:530-292-3478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17894124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist