Provider Demographics
NPI:1245655844
Name:BREWER, LISA (DMD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BREWER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4923 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-3252
Mailing Address - Country:US
Mailing Address - Phone:941-922-9332
Mailing Address - Fax:941-922-8769
Practice Address - Street 1:4923 CLARK RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-3252
Practice Address - Country:US
Practice Address - Phone:941-922-9332
Practice Address - Fax:941-922-8769
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13465122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist