1639528227 NPI number — MISS LISA CHRISTINA SMITH LAC, DOM

Table of content: MISS LISA CHRISTINA SMITH LAC, DOM (NPI 1639528227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639528227 NPI number — MISS LISA CHRISTINA SMITH LAC, DOM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
LISA
Provider Middle Name:
CHRISTINA
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LAC, DOM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639528227
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8361
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23226-0361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-497-8860
Provider Business Mailing Address Fax Number:
804-377-2223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9210 FOREST HILL AVE
Provider Second Line Business Practice Location Address:
SUITE B3
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23235-6880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-497-8860
Provider Business Practice Location Address Fax Number:
804-377-2223
Provider Enumeration Date:
06/06/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  0121000050 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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