Provider Demographics
NPI:1114204914
Name:LISA KAKISHITA DMD LLC
Entity type:Organization
Organization Name:LISA KAKISHITA DMD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARNET
Authorized Official - Last Name:KAKISHITA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-577-4429
Mailing Address - Street 1:833 SW 11TH AVE STE 414
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2118
Mailing Address - Country:US
Mailing Address - Phone:503-221-9439
Mailing Address - Fax:503-227-5923
Practice Address - Street 1:833 SW 11TH AVE
Practice Address - Street 2:#414
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2125
Practice Address - Country:US
Practice Address - Phone:503-221-9439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD81611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty