Provider Demographics
NPI:1952928251
Name:LISA M MA DMD, PLLC
Entity Type:Organization
Organization Name:LISA M MA DMD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:305-335-2252
Mailing Address - Street 1:5347 N SOCRUM LOOP RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-4256
Mailing Address - Country:US
Mailing Address - Phone:863-606-5721
Mailing Address - Fax:
Practice Address - Street 1:5347 N SOCRUM LOOP RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-4256
Practice Address - Country:US
Practice Address - Phone:863-606-5721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-02
Last Update Date:2021-08-17
Deactivation Date:2020-11-24
Deactivation Code:
Reactivation Date:2021-08-17
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental