Provider Demographics
NPI:1821196791
Name:LISULL, DEBRA O (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:O
Last Name:LISULL
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 1:2411 OAK VALLEY DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-9131
Mailing Address - Country:US
Mailing Address - Phone:734-761-1122
Mailing Address - Fax:734-761-9664
Practice Address - Street 1:2411 OAK VALLEY DR
Practice Address - Street 2:SUITE 600
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-9131
Practice Address - Country:US
Practice Address - Phone:734-761-1122
Practice Address - Fax:734-761-9664
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI13481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist