Provider Demographics
NPI:1124432349
Name:OTOUDE, LISA RAE (DMD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:RAE
Last Name:OTOUDE
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 1:14928 NICHOLS HALL DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-7504
Mailing Address - Country:US
Mailing Address - Phone:919-360-2353
Mailing Address - Fax:
Practice Address - Street 1:275 N NC 16 BUSINESS HWY STE 204B
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-3000
Practice Address - Country:US
Practice Address - Phone:704-275-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC109601223G0001X
TX326311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX9605Medicaid