Provider Demographics
NPI:1700924933
Name:LISA H SIDDALL DDS PC
Entity Type:Organization
Organization Name:LISA H SIDDALL DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:H
Authorized Official - Last Name:SIDDALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-256-9142
Mailing Address - Street 1:PO BOX 1133
Mailing Address - Street 2:407 S MAIN
Mailing Address - City:LELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49634
Mailing Address - Country:US
Mailing Address - Phone:231-256-9142
Mailing Address - Fax:231-256-9131
Practice Address - Street 1:407 S MAIN
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:MI
Practice Address - Zip Code:49634
Practice Address - Country:US
Practice Address - Phone:231-256-9142
Practice Address - Fax:231-256-9131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI16320122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty