Provider Demographics
NPI:1265203145
Name:PETERSON, LISA MICHELLE (DENTAL HYGIENIST)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MICHELLE
Other - Last Name:FLATHERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:611 N IRON BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4932
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:
Practice Address - Street 1:2211 E HARTSON AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-4152
Practice Address - Country:US
Practice Address - Phone:509-444-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00007270124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist