Provider Demographics
NPI:1760563928
Name:BURRELL, LISA ANDREA (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANDREA
Last Name:BURRELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:L
Other - Middle Name:A
Other - Last Name:BURRELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD, PC
Mailing Address - Street 1:5370 US HIGHWAY 78
Mailing Address - Street 2:SUITE 720
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087
Mailing Address - Country:US
Mailing Address - Phone:770-465-3400
Mailing Address - Fax:770-465-3480
Practice Address - Street 1:5370 STONE MOUNTAIN HWY # 78
Practice Address - Street 2:SUITE 720
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3581
Practice Address - Country:US
Practice Address - Phone:770-465-3400
Practice Address - Fax:770-465-3480
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0112091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00566167AMedicaid