Provider Demographics
NPI:1811040728
Name:JUDGE, LISA MARIA DDS PC
Entity Type:Organization
Organization Name:JUDGE, LISA MARIA DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-541-0101
Mailing Address - Street 1:1230 POWERS FERRY RD SE
Mailing Address - Street 2:SUITE #6
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-5495
Mailing Address - Country:US
Mailing Address - Phone:770-541-0101
Mailing Address - Fax:770-541-0102
Practice Address - Street 1:1230 POWERS FERRY RD SE
Practice Address - Street 2:SUITE #6
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5495
Practice Address - Country:US
Practice Address - Phone:770-541-0101
Practice Address - Fax:770-541-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0111801223G0001X
LA44301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00764112BMedicaid