Provider Demographics
NPI:1871858670
Name:SMITH, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10625 NE 68TH ST
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-7054
Mailing Address - Country:US
Mailing Address - Phone:425-822-2241
Mailing Address - Fax:425-827-5892
Practice Address - Street 1:10625 NE 68TH ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-7054
Practice Address - Country:US
Practice Address - Phone:425-822-2241
Practice Address - Fax:425-827-5892
Is Sole Proprietor?:No
Enumeration Date:2012-07-08
Last Update Date:2012-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH60010814124Q00000X
WAVA00049715183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No183700000XPharmacy Service ProvidersPharmacy Technician