Provider Demographics
NPI:1740473594
Name:GITELSON, LISA M (DMD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:GITELSON
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 1:4734 RIVER RD N
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-4536
Mailing Address - Country:US
Mailing Address - Phone:503-463-4663
Mailing Address - Fax:
Practice Address - Street 1:4734 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4536
Practice Address - Country:US
Practice Address - Phone:503-463-4663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD76231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice