Provider Demographics
NPI:1124481585
Name:DAVIS, LISA A
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:300 W WIEUCA RD NE
Mailing Address - Street 2:BUILDING 2 SUITE 210
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-3352
Mailing Address - Country:US
Mailing Address - Phone:404-252-4220
Mailing Address - Fax:
Practice Address - Street 1:300 W WIEUCA RD NE
Practice Address - Street 2:BUILDING 2 SUITE 210
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-3352
Practice Address - Country:US
Practice Address - Phone:404-252-4220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-03
Last Update Date:2016-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012325122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist