Provider Demographics
NPI:1215142765
Name:LISTER, DAVID B (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:B
Last Name:LISTER
Suffix:
Gender:M
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:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:WEWAHITCHKA
Mailing Address - State:FL
Mailing Address - Zip Code:32465-0068
Mailing Address - Country:US
Mailing Address - Phone:850-639-4565
Mailing Address - Fax:850-639-6565
Practice Address - Street 1:403 SOUTH HIGHWAY 71
Practice Address - Street 2:
Practice Address - City:WEWAHITCHKA
Practice Address - State:FL
Practice Address - Zip Code:32465
Practice Address - Country:US
Practice Address - Phone:850-639-4565
Practice Address - Fax:850-639-6565
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL154371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice