Provider Demographics
NPI:1912005778
Name:LIZASO, RAUL (DMD)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:
Last Name:LIZASO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20170 PINES BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-1202
Mailing Address - Country:US
Mailing Address - Phone:954-430-1717
Mailing Address - Fax:954-430-3049
Practice Address - Street 1:20170 PINES BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-1202
Practice Address - Country:US
Practice Address - Phone:954-430-1717
Practice Address - Fax:954-430-3049
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00141961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice