Provider Demographics
NPI:1306150958
Name:LISA J. MCDONALD, DMD, INC.
Entity type:Organization
Organization Name:LISA J. MCDONALD, DMD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:314-727-1319
Mailing Address - Street 1:7247 DELMAR BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130
Mailing Address - Country:US
Mailing Address - Phone:314-727-1319
Mailing Address - Fax:214-727-7221
Practice Address - Street 1:7247 DELMAR BOULEVARD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130
Practice Address - Country:US
Practice Address - Phone:314-727-1319
Practice Address - Fax:214-727-7221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010220201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty