Provider Demographics
NPI:1659722940
Name:ANDERSON, LISA (DDS)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:ANDERSON
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 1:945 W BROADWAY AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-8217
Mailing Address - Country:US
Mailing Address - Phone:307-734-5200
Mailing Address - Fax:
Practice Address - Street 1:945 W BROADWAY AVE APT 201
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8217
Practice Address - Country:US
Practice Address - Phone:307-734-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1630122300000X
SDD1109122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist