Provider Demographics
NPI:1770791956
Name:PHILLIPS, LISA DATTA (DDS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DATTA
Last Name:PHILLIPS
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 1:14073 DETROIT DR
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80602-8874
Mailing Address - Country:US
Mailing Address - Phone:813-404-7087
Mailing Address - Fax:
Practice Address - Street 1:14422 ORCHARD PKWY
Practice Address - Street 2:STE 200
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80023-9273
Practice Address - Country:US
Practice Address - Phone:303-452-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-19
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17862122300000X
CO10072122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist