Provider Demographics
NPI:1649625518
Name:CANDON, LISA ATLAS (DDS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ATLAS
Last Name:CANDON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:ATLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:16748 KRISHNA LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-1638
Mailing Address - Country:US
Mailing Address - Phone:704-763-8188
Mailing Address - Fax:
Practice Address - Street 1:2700 COLTSGATE RD STE 204
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-3573
Practice Address - Country:US
Practice Address - Phone:704-749-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC109131223P0221X
OH30.0249961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice