Provider Demographics
NPI:1205087996
Name:LICHTWARDT, MEGAN ELISSA (DMD)
Entity type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:ELISSA
Last Name:LICHTWARDT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MS
Other - First Name:MEGAN
Other - Middle Name:ELISSA
Other - Last Name:GILBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:5122 OLYMPIC DRIVE SUITE B102
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335
Mailing Address - Country:US
Mailing Address - Phone:253-851-1190
Mailing Address - Fax:253-851-2183
Practice Address - Street 1:5122 OLYMPIC DRIVE SUITE B102
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335
Practice Address - Country:US
Practice Address - Phone:253-851-1190
Practice Address - Fax:253-851-2183
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE608190891223G0001X
PADS0374791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice