Provider Demographics
NPI:1932660792
Name:DR. LISA F. DAVIS, DMD, PLLC
Entity Type:Organization
Organization Name:DR. LISA F. DAVIS, DMD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GUANAH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:704-637-6717
Mailing Address - Street 1:1107 STATESVILLE BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-2287
Mailing Address - Country:US
Mailing Address - Phone:704-637-6717
Mailing Address - Fax:704-637-6717
Practice Address - Street 1:1107 STATESVILLE BLVD STE C
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2287
Practice Address - Country:US
Practice Address - Phone:704-637-6717
Practice Address - Fax:704-637-6717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1306869664Medicaid