Provider Demographics
NPI:1326181322
Name:SKUTAK, LISA MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:SKUTAK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 EAGLE NEST BOULEVARD
Mailing Address - Street 2:SUITE E
Mailing Address - City:ROTHSCHILD
Mailing Address - State:WI
Mailing Address - Zip Code:54476
Mailing Address - Country:US
Mailing Address - Phone:715-355-4433
Mailing Address - Fax:715-355-4414
Practice Address - Street 1:700 EAGLE NEST BOULEVARD
Practice Address - Street 2:SUITE E
Practice Address - City:ROTHSCHILD
Practice Address - State:WI
Practice Address - Zip Code:54476
Practice Address - Country:US
Practice Address - Phone:715-355-4433
Practice Address - Fax:715-355-4414
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5176-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice