1700867702 NPI number — DR. LISA MARIE BANNING DMD, MSD

Table of content: DR. LISA MARIE BANNING DMD, MSD (NPI 1700867702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700867702 NPI number — DR. LISA MARIE BANNING DMD, MSD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANNING
Provider First Name:
LISA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD, MSD
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:
1700867702
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 W BROAD ST
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
TAMAQUA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18252-1914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-952-6150
Provider Business Mailing Address Fax Number:
570-952-6151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 W BROAD ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
TAMAQUA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18252-1914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-952-6150
Provider Business Practice Location Address Fax Number:
570-952-6151
Provider Enumeration Date:
11/08/2005

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: 1223X0400X , with the licence number:  DS-029165-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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