Provider Demographics
NPI:1972667137
Name:DEAN, LISA (DMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DEAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:R
Other - Last Name:DEAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1592 DIEDERICH BLVD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KY
Mailing Address - Zip Code:41169-1676
Mailing Address - Country:US
Mailing Address - Phone:606-836-9962
Mailing Address - Fax:606-836-4668
Practice Address - Street 1:1592 DIEDERICH BLVD
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KY
Practice Address - Zip Code:41169-1676
Practice Address - Country:US
Practice Address - Phone:606-836-9962
Practice Address - Fax:606-836-4668
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY68901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60068905Medicaid
OH2436288,9962Medicaid
KY6112675841OtherTAX ID