Provider Demographics
NPI:1386409118
Name:VARELA, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VARELA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 SYMINGTON DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25404-1896
Mailing Address - Country:US
Mailing Address - Phone:304-279-8379
Mailing Address - Fax:
Practice Address - Street 1:58 WARM SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25404-3800
Practice Address - Country:US
Practice Address - Phone:304-267-0250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD7152124Q00000X
VA0402207102124Q00000X
WV2836124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist