Provider Demographics
NPI:1922235027
Name:EDSTROM, LISA ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:EDSTROM
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 1:3436 DENMARK AVE
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1088
Mailing Address - Country:US
Mailing Address - Phone:651-452-4455
Mailing Address - Fax:
Practice Address - Street 1:3436 DENMARK AVE
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1088
Practice Address - Country:US
Practice Address - Phone:651-452-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist