Provider Demographics
NPI:1326884677
Name:ANDERSON, LISA (DENTAL HYGIENIST)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12030 E B C TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WI
Mailing Address - Zip Code:53525-8708
Mailing Address - Country:US
Mailing Address - Phone:608-290-9631
Mailing Address - Fax:
Practice Address - Street 1:74 ECLIPSE CTR
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3550
Practice Address - Country:US
Practice Address - Phone:608-361-0311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-06
Last Update Date:2024-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7001489124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist