Provider Demographics
NPI:1669406526
Name:GOFF, LISA A (DMD,PA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:GOFF
Suffix:
Gender:F
Credentials:DMD,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 N WICKHAM RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2200
Mailing Address - Country:US
Mailing Address - Phone:321-242-2766
Mailing Address - Fax:321-242-2463
Practice Address - Street 1:2717 N WICKHAM RD
Practice Address - Street 2:SUITE 1
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2200
Practice Address - Country:US
Practice Address - Phone:321-242-2766
Practice Address - Fax:321-242-2463
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0012699122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist