Provider Demographics
NPI:1134925340
Name:MOUTAWAKIL, LISA CARDENAS
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:CARDENAS
Last Name:MOUTAWAKIL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 CENTRAL PARK DR STE 101
Mailing Address - Street 2:
Mailing Address - City:STEAMBOAT SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80487-8853
Mailing Address - Country:US
Mailing Address - Phone:970-879-1632
Mailing Address - Fax:
Practice Address - Street 1:940 CENTRAL PARK DR STE 101
Practice Address - Street 2:
Practice Address - City:STEAMBOAT SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80487-8853
Practice Address - Country:US
Practice Address - Phone:970-879-1632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.002027191124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist