Provider Demographics
NPI:1962575977
Name:GUSHIN, LISA (DDS)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:GUSHIN
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 1:203 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3409
Mailing Address - Country:US
Mailing Address - Phone:910-484-1771
Mailing Address - Fax:
Practice Address - Street 1:203 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3409
Practice Address - Country:US
Practice Address - Phone:910-484-1771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC69081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC586286OtherUNITED CONCORDIA
NC9010FOtherBCBS
NC899010FMedicaid