Provider Demographics
NPI:1386102879
Name:LISCO, COLLEEN QUINN (DDS)
Entity type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:QUINN
Last Name:LISCO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MS
Other - First Name:COLLEEN
Other - Middle Name:MARIE
Other - Last Name:QUINN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1610 MCGUCKIAN ST
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-4020
Mailing Address - Country:US
Mailing Address - Phone:410-268-5046
Mailing Address - Fax:
Practice Address - Street 1:1610 MCGUCKIAN ST
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-4020
Practice Address - Country:US
Practice Address - Phone:410-268-5046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16737122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist