Provider Demographics
NPI:1124489190
Name:HOFSTAD, LISA (DMD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HOFSTAD
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 1:424 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32351-1412
Mailing Address - Country:US
Mailing Address - Phone:904-514-3007
Mailing Address - Fax:
Practice Address - Street 1:424 N 14TH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351-1412
Practice Address - Country:US
Practice Address - Phone:904-514-3007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0014865122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist