Provider Demographics
NPI:1508046988
Name:LISELL, ANDREA DECERCE (DMD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:DECERCE
Last Name:LISELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:LOUISE
Other - Last Name:DECERCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1109 OATES ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-3823
Mailing Address - Country:US
Mailing Address - Phone:305-505-1101
Mailing Address - Fax:
Practice Address - Street 1:8955 WOOD RD BLDG 1
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-5005
Practice Address - Country:US
Practice Address - Phone:301-400-2422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18169122300000X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist