Provider Demographics
NPI:1992990832
Name:GROSSO, LISA T (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:T
Last Name:GROSSO
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 EAST ST STE 16
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-1926
Mailing Address - Country:US
Mailing Address - Phone:925-676-2160
Mailing Address - Fax:925-676-2165
Practice Address - Street 1:2425 EAST ST STE 16
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520
Practice Address - Country:US
Practice Address - Phone:925-676-2160
Practice Address - Fax:925-676-2165
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA420501223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics