Provider Demographics
NPI:1669776464
Name:JOHN, NISHA LIZ (DDS)
Entity type:Individual
Prefix:
First Name:NISHA
Middle Name:LIZ
Last Name:JOHN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12040 ASHAWAY LANE
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-3038
Mailing Address - Country:US
Mailing Address - Phone:803-446-2831
Mailing Address - Fax:719-583-1801
Practice Address - Street 1:1900 EAST PIONEER PARKWAY
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010
Practice Address - Country:US
Practice Address - Phone:803-446-2831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-07
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN102711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice