Provider Demographics
NPI:1649653957
Name:MA, LISA M (DMD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:MA
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 1:5347 N SOCRUM LOOP RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-4256
Mailing Address - Country:US
Mailing Address - Phone:863-606-5721
Mailing Address - Fax:
Practice Address - Street 1:5347 N SOCRUM LOOP RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-4256
Practice Address - Country:US
Practice Address - Phone:863-606-5721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 213261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice