Provider Demographics
NPI:1912094830
Name:FLETCHER, LISA E (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:E
Last Name:FLETCHER
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 1:614 BERRY RD
Mailing Address - Street 2:
Mailing Address - City:BULLS GAP
Mailing Address - State:TN
Mailing Address - Zip Code:37711-3821
Mailing Address - Country:US
Mailing Address - Phone:850-218-6789
Mailing Address - Fax:850-609-6796
Practice Address - Street 1:1047 S. HWY 92
Practice Address - Street 2:SUITE A
Practice Address - City:DANDRIDGE
Practice Address - State:TN
Practice Address - Zip Code:37725
Practice Address - Country:US
Practice Address - Phone:865-397-2956
Practice Address - Fax:865-299-7988
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11049122300000X
TN117091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11049OtherLICENSE NUMBER
FL67946OtherBLUE CROSS BLUE SHIELD FL
FL529529OtherUNITED CONCORDIA INS CO