Provider Demographics
NPI:1295170876
Name:ECKARDT, LISA MARIE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:ECKARDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:HANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2690 NE KRESKY AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2412
Mailing Address - Country:US
Mailing Address - Phone:360-330-9595
Mailing Address - Fax:360-330-9580
Practice Address - Street 1:2690 NE KRESKY AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2412
Practice Address - Country:US
Practice Address - Phone:360-330-9595
Practice Address - Fax:360-330-9580
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00004950124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist